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'Doctor-Shopping' for Painkillers Common After Broken-Bone Surgery, Study Finds PDF Print E-mail
Title: 'Doctor-Shopping' for Painkillers Common After Broken-Bone Surgery, Study Finds
Category: Health News
Created: 8/29/2014 9:35:00 AM
Last Editorial Review: 8/29/2014 12:00:00 AM
Study finds plain cigarette pack fears 'unfounded' PDF Print E-mail

"Cigarette plain packaging fear campaign unfounded," reports The Guardian.

After Australia introduced plain packaging laws in 2012, opponents of the legislation argued it would lead to a number of unintended consequences, including:

  • the market would become flooded by cheap Asian brands
  • smokers would be more likely to buy illegal unbranded tobacco (including raw unbranded loose tobacco known locally in Australia as "chop-chop")
  • smokers would be less likely to buy their cigarettes from smaller mixed businesses such as convenience stores and petrol stations, meaning that small businesses would suffer

But a new study conducted in Victoria, Australia, suggests these fears are unfounded.

Researchers compared the responses smokers gave in a telephone survey one year before the introduction of standardised packaging, with responses given one year after its introduction.

The study found no evidence the introduction of standardised packaging had changed the proportion of people purchasing from small mixed-business retailers, purchasing cheap brands imported from Asia, or using illicit tobacco.

But this study did not investigate whether there had been an increase in the use of counterfeit branded tobacco products. The researchers noted that smokers may be unaware they are smoking counterfeit products.

In conclusion, the study suggests there is no evidence for many of the "fears" proposed by opponents of standardised packaging.


Where did the story come from?

The study was carried out by researchers from the Centre for Behavioural Research in Cancer in Melbourne, Australia.

It was supported by Quit Victoria, with funding from VicHealth and the Department of Health for the Victorian Smoking and Health annual survey.

The study was published in the peer-reviewed journal BMJ Open, which is open access, so the study can be read online or downloaded for free.

The results of the study were well reported by the UK media.


What kind of research was this?

This was a serial cross-sectional study (a cross-sectional study at different time points) that aimed to determine whether there was any evidence that the introduction of standardised packaging in Australia had changed:

  • the proportion of current smokers who usually purchased their tobacco products from larger discount outlets such as supermarkets, compared with small mixed-business retail outlets
  • the prevalence of the regular use of low-cost brands imported from Asia
  • the use of illicit unbranded tobacco

In Australia, since 2012 all tobacco products have to be sold in standardised dark brown packaging with large graphic health warnings. Brand names are printed in a standardised position with standardised lettering.

The researchers state opponents of plain packaging have suggested its introduction could mean smokers would be less likely to purchase from small mixed-business retailers, more likely to purchase cheap brands imported from Asia, and more likely to use illicit tobacco.


What did the research involve?

Smokers aged 18 and over in Victoria, Australia were identified in an annual population telephone survey (the Victorian Smoking and Health Survey).

They were asked about:

  • the place they usually purchase tobacco products from (supermarkets, specialist tobacconists, small mixed businesses, petrol stations or other venues, including informal sellers)
  • their use of low-cost Asian brands (whether their main brand was a low-cost Asian brand)
  • their use of unbranded illicit tobacco (whether they had bought or purchased any unbranded tobacco)

The researchers compared answers from three annual surveys: 

  • 2011 – a year prior to the implementation of standardised packaging
  • 2012 – during roll-out
  • 2013 – a year after implementation


What were the basic results?

A total of 754 smokers were surveyed in 2011, 590 in 2012 and 601 in 2013.

The researchers found:

  • the proportion of smokers purchasing from supermarkets did not increase and the percentage purchasing from small mixed-business outlets did not decline between 2011 and 2013
  • the prevalence of low-cost Asian brands was low and did not increase between 2011 and 2013
  • the proportion reporting current use of unbranded illicit tobacco did not change significantly between 2011 and 2013


How did the researchers interpret the results?

The researchers concluded that, "One year after implementation, this study found no evidence of the major unintended consequences concerning loss of smoker patrons from small retail outlets, flooding of the market by cheap Asian brands and use of illicit tobacco predicted by opponents of plain packaging in Australia."



The study found no evidence the introduction of standardised packaging had changed the proportion of people purchasing from small mixed-business retailers, purchasing cheap brands imported from Asia, or using illicit tobacco in Victoria, Australia.

However, this survey was only conducted in Victoria and only among English-speaking residents, so further studies are required to confirm the generalisability of the findings. As with all surveys, there is the possibility of respondent error and misreporting.

Further studies are required to investigate whether the introduction of standardised packaging has increased the use of counterfeit branded tobacco products, as this was not assessed.

Overall, the results of this study suggest there is no evidence behind many of the "fears" proposed by opponents of standardised packaging.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

'Plain' packaging not a boost to illegal tobacco use, study suggests. BBC News, August 29 2014

Australia shows that plain tobacco packaging significantly cuts smoking. The Independent, August 29 2014

Cigarette plain packaging fear campaign unfounded, Victoria study finds. The Guardian, August 29 2014

Plain Cigarette Packs Do Not Hurt Retailers. Sky News, August 29 2014

Links To Science

Scollo M, Zacher M, Durkin S, Wakefield M. Early evidence about the predicted unintended consequences of standardised packaging of tobacco products in Australia: a cross-sectional study of the place of purchase, regular brands and use of illicit tobacco. BMJ Open. Published online July 18 2014

Polyp Removal Doesn't Always Signal Raised Colon Cancer Risk, Study Says PDF Print E-mail
Title: Polyp Removal Doesn't Always Signal Raised Colon Cancer Risk, Study Says
Category: Health News
Created: 8/27/2014 5:36:00 PM
Last Editorial Review: 8/28/2014 12:00:00 AM
Tomato-rich diet 'reduces prostate cancer risk' PDF Print E-mail

“Tomatoes ‘cut risk of prostate cancer by 20%’,” the Daily Mail reports, citing a study that found men who ate 10 or more portions a week had a reduced risk of the disease.

The study in question gathered a year’s dietary information from 1,806 men who were found to have prostate cancer and 12,005 who were clear after random prostate checks. The researchers compared the diets and adjusted the results to take into account factors such as age, family history of prostate cancer and ethnicity.

They found that men who ate more than 10 portions of tomatoes or tomato products per week have an 18% reduced risk of prostate cancer compared to men who ate less than 10.

As this was a case controlled study, and not a randomised controlled trial, it cannot prove that eating more tomatoes prevents prostate cancer. It can only show an association.

The association is biologically plausible, because tomatoes are a rich source of lycopene, a nutrient thought to protect against cell damage. However, the jury is still out on whether it really does protect cells.

So a healthy, balanced diet, regular exercise and stopping smoking are still the way to go. It’s unlikely that focusing on one particular food will improve your health.


Where did the story come from?

The study was carried out by researchers from the University of Bristol, the National Institute for Health Research (NIHR) Bristol Nutrition Biomedical Research Unit, Addenbrooke’s Hospital in Cambridge and the University of Oxford. It was funded by the NIHR and Cancer Research UK.

The study was published in the peer-reviewed medical journal Cancer Epidemiology, Biomarkers and Prevention. The study is open-access so it is free to read online or download.

In general, the media reported the story accurately but also reported different numbers of study participants, ranging from 1,800 to 20,000. This is because out of the 23,720 men who were initially included in the study, a proportion were excluded from the analyses due to missing questionnaires.

Several news sources have also reported that eating the recommended five portions of fruit or veg per day reduced the risk of prostate cancer by 24% compared to 2.5 servings or less per day. This seems to have come directly from the lead researcher, but these figures are not clearly presented in the research paper.


What kind of research was this?

This was a case-control study looking at the diet, lifestyle and weight of men who had had a prostate check and were subsequently diagnosed with (cases) and without (controls) prostate cancer. The researchers wanted to see if there were any factors that reduced the risk of being diagnosed with prostate cancer.

A previous systematic review suggested that a diet high in calcium is associated with an increased risk of prostate cancer and that diets high in selenium and lycopene are associated with reduced risk. Selenium is a chemical element essential for life that is found in animals and plants, but high levels are toxic. Lycopene is a nutrient found in red foods such as tomatoes and pink grapefruit.

The researchers defined intake of selenium and lycopene as the “prostate cancer dietary index”. They looked at whether there was an association between men’s index scores and their risk of having prostate cancer.

In addition, in 2007, the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) made eight recommendations on diet, exercise and weight for cancer prevention. 

However, recent research has shown conflicting results as to whether these recommendations are applicable to prostate cancer. One large European study found that men who followed the recommendations did not have a lower general prostate cancer risk, and the other found that men did have a reduced risk of aggressive prostate cancer.

The researchers wanted to see if these recommendations should be changed to include any of the prostate cancer dietary index components for men and/or men at higher risk of prostate cancer.


What did the research involve?

The researchers used data collected from a large UK study called the ProtecT trial. In this trial, 227,300 randomly selected men aged 50 to 69 were invited to have a prostate check between 2001 and 2009.

Nearly half of the men then had a prostate specific antigen (PSA) test and 11% of them went on to have further investigations. Before the test they were asked to fill out questionnaires on:

  • lifestyle
  • diet
  • alcohol intake
  • medical history
  • family history

They were also asked to provide information on their:

  • physical activity level
  • body mass index (BMI)
  • waist circumference
  • body size aged 20, 40 and at the time they entered the study

Body size was self-estimated by looking at pictures on a scale of 1 to 9. All those selecting 1 to 3 were categorised as normal weight and those selecting 4 to 9 were considered overweight/obese.

From this study the researchers identified 2,939 men who had been diagnosed with prostate cancer and matched them with 20,781 randomly selected men by age and GP practice who did not have prostate cancer to act as controls. They then excluded anyone who did not return the questionnaires and those who did not provide all of the body metrics.

This gave a sample of 1,806 men with prostate cancer and 12,005 controls.

The dietary questionnaires assessed how frequently they had consumed 114 items of food over the previous 12 months. This included an estimate of portion sizes.

From this information, the men were assigned a score to reflect how well they had achieved the first six of the eight WCRF/AICR recommendations (they did not have enough information for “salt consumption” or “dietary supplements”).

Adherence to each recommendation was scored (1 – complete adherence, 0.5 – partial adherence or 0 – non-adherence), giving an overall score between 0 and 6.

The researchers also looked at the intake of components of the “prostate cancer dietary index”: calcium, selenium and tomato products which they used as an indicator of lycopene intake (tomato juice, tomato sauce, pizza and baked beans). To be scored as adherent, men had to:

  • eat less than 1,500mg of calcium per day
  • eat more than 10 servings of tomato and tomato products per week
  • eat between 105 and 200µg of selenium per day

Statistical analyses were then performed to determine the risk of low or high grade prostate cancer according to adherence to the WCRF/AICR recommendations or intake of any of the three dietary components of the prostate cancer dietary index. The results were adjusted to take into account the following confounders:

  • age
  • family history of prostate cancer
  • self-reported diabetes
  • ethnic group
  • occupational class
  • smoking status
  • total energy intake
  • BMI


What were the basic results?

After adjusting for possible confounding factors:

  • being adherent to the tomato and tomato product recommendation by eating 10 or more servings of tomatoes per week was associated with an 18% reduced risk of prostate cancer compared to eating less than 10 servings (odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.97)
  • each component of the “prostate cancer dietary index” that the men adhered to was associated with a 9% reduction in risk of prostate cancer (OR 0.91, 95% CI 0.84 to 0.99)
  • the overall WCFR/AICR adherence score was not associated with a decreased risk of prostate cancer (OR 0.99, 95% CI 0.94 to 1.05)
  • every 0.25 increase in the score for adherence to the plant food recommendation was associated with a 6% reduced overall risk of prostate cancer (OR 0.94, 95% CI 0.89 to 0.99)

A 0.25 increase in adherence score could be achieved by increasing fruit and vegetable intake from less than 200g/day to between 200 and 400g/day, or by increasing fruit and vegetable intake from between 200 and 400g/day to 400g/day or more (400g is equivalent to five portions) or by changing intake of unprocessed cereals (grains) and/or pulses (legumes).


How did the researchers interpret the results?

The researchers concluded that, “in addition to meeting the optimal intake for the three dietary factors associated with prostate cancer, men should maintain a healthy weight and an active lifestyle to reduce risk of developing prostate cancer, cardiovascular diseases and diabetes”. They also say that “high intake of plant foods and tomato products in particular may help protect against prostate cancer, which warrants further investigations”.



This large study has shown an association between the consumption of more than 10 portions of tomatoes per week and an 18% reduction in risk of prostate cancer. However, as this was a case controlled study, and not a randomised controlled trial, it cannot prove that eating more tomatoes prevents prostate cancer.

Strengths of the study include its large size and attempts to account for potential confounding factors, although there are some limitations to the study, including:

  • reliance on the accuracy of the dietary questionnaires
  • broad categories for self-estimate of body size

This study does not provide enough evidence to change the recommendations for reducing the risk of prostate cancer. A healthy, balanced diet, regular exercise and stopping smoking are still the way to go, rather than relying on eating one exclusive food type such as tomatoes.

Following the eight WCRF/AICR recommendations as listed above should also help prevent against other types of cancer as well as chronic diseases such as obesity and type 2 diabetes. 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Tomatoes 'cut risk of prostate cancer by 20%': It takes 10 portions a week - but even baked beans count. Daily Mail, August 28 2014

Tomatoes 'important in prostate cancer prevention'. BBC News, August 27 2014

Tomato-rich diet can lower prostate cancer risk by a fifth, scientists claim. The Independent, August 27 2014

New research suggests men who eat more than 10 portions of tomatoes a week are less likely to develop prostate cancer. ITV News, August 27 2014

Links To Science

Er V, Lane JA, Martin RM, et al. Adherence to dietary and lifestyle recommendations and prostate cancer risk in the Prostate Testing for Cancer and Treatment (ProtecT) trial. Cancer Epidemiology, Biomarkers and Prevention. Published online July 13 2014

Depression therapy aids other cancer symptoms PDF Print E-mail

"Depression therapy could help cancer patients fight illness," reports The Daily Telegraph.

The headline follows a study of intensive treatment of clinical depression given to people who had both depression and cancer – delivered as part of their cancer care. It found that not only did people’s mood improve, but cancer-related symptoms such as pain and fatigue were also reduced compared to that seen with the usual care given.

The treatment programme, called Depression Care for People with Cancer (DCPC), involves a team of specially trained cancer nurses and psychiatrists who work closely with the patient’s cancer doctors and GP.

A related study, also published today, found that clinical depression is a common problem for people living with cancer. For example, it found that around one in eight people with lung cancer also had clinical depression.

It should be noted that the trial involved patients with a good outlook for their cancer, which may have been a factor in their response to treatment for depression.

However, a second trial of the depression treatment programme, this time involving lung cancer patients, also published today but not analysed here, showed a similar benefit, despite their poorer cancer prognosis.

This was a randomised controlled trial, which is the best type of study to examine the effectiveness of healthcare treatments, so the results are likely to be reliable. It is hoped that the positive results will be replicated in larger populations.


Where did the story come from?

The study was carried out by researchers from the Universities of Oxford and Edinburgh, and was funded by Cancer Research UK and the Scottish government.

The study was published in the peer-reviewed medical journal The Lancet.

The study is one of three depression-related cancer studies published by The Lancet.

The first looks at how common clinical depression is in cancer patients.

The third study assesses how effective the DCPC programme is in patients with cases of lung cancer that have a poor prognosis.

The study was covered fairly by the UK media.


What kind of research was this?

This was a randomised controlled trial of an integrated treatment programme for clinical depression in patients with cancer, compared to the results seen with usual care.

The authors point out that clinical depression affects about 10% of people with cancer and is associated with: worse anxiety, pain, fatigue and functioning; suicidal thoughts; and poor adherence to anticancer treatments.

However, at present, there is no good evidence for how best to treat depression in cancer patients and how to integrate treatment into their cancer care.

Their integrated treatment programme involves a psychiatrist and the care manager working with the patient’s specialist doctor, GP and cancer nurses to provide an intensive systematic treatment for depression, including both drugs and psychological treatment.

It’s worth pointing out that what is new here is not the actual treatments for depression – rather the way they are delivered, as an integrated part of the patient’s cancer care.


What did the research involve?

Between 2008 and 2011, researchers enrolled 500 participants attending three cancer centres in Scotland. Participants were aged 18 or over, with a good cancer prognosis – with a predicted survival of at least a year. They had all been diagnosed with clinical depression of at least four weeks' duration.

253 participants were randomly assigned to the new DCPC programme, with 247 assigned to usual care.

In the DCPC group, depression care was delivered by specially trained cancer nurses, under the supervision of a psychiatrist. The programme was designed to be integrated with the patient’s cancer care, with psychiatrists working in collaboration with the patient’s oncology team and their GP.

The nurses established a therapeutic relationship with the patient, provided information about depression and its treatment, delivered psychological interventions and monitored progress, using a validated depression questionnaire. The psychiatrists supervised treatment, advised GPs about prescribing antidepressants and provided direct consultations with patients who were not improving.

The initial treatment phase comprised a maximum of 10 sessions with the nurse (at the clinic or, if necessary, by telephone) over a four-month period. After this, the patient’s progress was monitored monthly by telephone for a further eight months, and additional sessions with the nurse were provided for patients not meeting treatment targets. All cases were reviewed on a weekly basis, in supervision meetings attended by nurses and a psychiatrist.

In the usual care group, the patient's GP and cancer doctors were informed about the clinical depression diagnosis and asked to treat their patients as they normally would. This might involve the GP prescribing antidepressants, or a referral of the patient to mental health services for assessment or psychological treatment.

At 24 weeks, researchers looked at the patient's primary response to their treatment, defined as at least a 50% reduction in depression severity and measured using a self-rated symptom checklist. A 50% reduction in score has been shown to be comparable to no longer meeting diagnostic criteria for major depression.

Researchers also looked at each patient’s levels of anxiety, pain, fatigue, physical and social functioning, as well as their overall health and quality of life, using validated questionnaires, and the patient’s opinion of the quality of depression care.

They analysed the results using standard statistical methods.


What were the basic results?

Researchers found that in 62% of participants in the DCPC group, the severity of depression decreased by 50% or more, compared with a 17% decrease in the usual care group (absolute difference 45%, 95% confidence interval (CI) 37 to 53; adjusted odds ratio (OR) 8.5, 95% CI 5.5 to 13.4).

Compared with patients in the usual care group, participants in the DCPC group also had less anxiety, pain and fatigue, as well as better functioning, health and quality of life. They also rated their depression care as being better.

During the study, 34 cancer-related deaths occurred (19 in the DCPC group, 15 in the usual care group); one patient in the DCPC group was admitted to a psychiatric ward and one patient in this group attempted suicide. None of these events were judged to be related to the trial's treatments or procedures.


How did the researchers interpret the results?

The researchers say their findings suggest that DCPC is an effective treatment for clinical depression in patients with cancer, and also offers a model for the treatment of depression occurring with other chronic medical conditions.

According to lead author Professor Michael Sharpe, from the University of Oxford in the UK: “The huge benefit that DCPC delivers for patients with cancer and depression shows what we can achieve for patients if we take as much care with the treatment of their depression as we do with the treatment of their cancer.”



Not surprisingly, this well-conducted study suggests that offering cancer patients with clinical depression an intensive, systematic treatment for depression involving all the people involved in their care, works better than the current approach.

As the authors point out, the trial had some limitations. The sample was mainly women receiving follow-up or adjuvant treatment for breast and gynaecological cancers, so it is unclear whether the findings are generalisable to other cancer patients.

Also, patients and their GPs could not be “masked” as to whether they were in the DCPC group or the group receiving usual care, which might have influenced the findings.

The striking results for patients in the DCPC group is probably attributable to treatment for depression being intensive, systematically implemented and integrated with the patient’s cancer care.

It is noteworthy that in the group receiving usual care, prescribing antidepressants was not actively managed – by, for example, changing the drug or adjusting the dose, according to the patient’s response. Few patients in this group received psychological treatment, despite the option being available.

Due to the very positive results achieved using the DCPC approach, the programme is likely to be assessed using other groups of people with cancer. If it continues to prove successful, it may become part of standard cancer treatment protocols.

If you are concerned that you have mental health problems that are being left untreated, talk to your cancer nurse or GP. They should be able to provide extra support and treatment as required.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Cancer patients with depression 'are being overlooked'. BBC News, August 28 2014

Do more for depressed cancer patients – study. The Guardian, August 28 2014

Depression therapy could help cancer patient fight illness. The Daily Telegraph, August 28 2014

Study: Depression among cancer patients 'overlooked'. ITV News, August 28 2014

Links To Science

Sharpe M, Walker J, Hansen CH, et al. Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial. The Lancet. Published online August 28 2014

Depression in cancer 'overlooked' PDF Print E-mail
Three-quarters of cancer patients who are depressed are not getting the psychological therapy they need, researchers say.
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