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New Online Services Tout Low-Cost Medical Tests
By NICK TIMIRAOS
June 20, 2006; Page D4 

Wendy's International Inc., in a breakthrough that gives it an edge in serving healthier fast food, is eliminating most artery-clogging trans fats from its menu.

Beginning in August, the country's third-largest burger chain will sell french fries and chicken sandwiches and strips that either have no trans fats or just a fraction of what they now absorb while being deep-fried.

Its hamburgers still will contain small amounts of the substance, which occur naturally in beef and dairy products. Earlier this year, Wendy's introduced a salad line it calls trans fat-free.

The culmination of nearly two years of testing and research, the company's latest move is likely to be cheered by dietitians and a medical community increasingly concerned about the relationship between trans fats and heart disease.

It also is certain to increase pressure on rivals McDonald's Corp., Burger King Holdings Inc. and other fast-food chains to offer similar fare -- particularly french fries, which are considered a major source of trans fats.

McDonald's has been working for years on a trans fat-free fry that doesn't compromise taste. A spokeswoman said last week that the search is "taking longer than anticipated, [but] we continue to progress in our testing, and we are determined to get it right for our customers."

Lori Estrada, Wendy's senior vice president for research and development, said tests in several markets around the U.S. and Canada showed "that consumers couldn't tell the difference in taste" between fries or chicken cooked in the current oil and those in the new one.

Wendy's experimented with more than a half dozen cooking oils before settling on a proprietary corn-and-soy blend, produced for it by agribusiness giant Cargill Inc.

Not only does the oil essentially eliminate trans fats in fries and breaded chicken, but it also shrinks the amount of saturated fats they contain, which could be another plus for Wendy's marketers.

Fries in Kids' Meals, which now contain 3.5 grams of trans fat, will have none when the new oil is introduced. The item Wendy's sells with the most trans fat, Great Biggie fries, will have that amount reduced to 0.5 gram from 7 grams, a drop of about 93%.

With 6,700 restaurants, Wendy's becomes the largest chain in the U.S. to virtually ban trans fats. Other restaurateurs that have done so include Panera Bread Co., Ruby Tuesday Inc., California Pizza Kitchen Inc. and closely held Legal Sea Food of Boston.

Ian Rowden, Wendy's chief marketing officer, said in an interview Wednesday that while the trans fat-free move "is a big position for us to take from a public relations point of view," he doubts it will be mentioned in TV commercials. It will, however, be noted on packaging, in-store signage and on the chain's Web site, Mr. Rowden said.

Besides not compromising the food's taste, the new oil had to be cost-neutral, he said. It does that in part because it replaces two current shortenings, one that's used for fries and another for chicken.

In January, the Food and Drug Administration required food processors to disclose trans fat content on labels. The FDA has no such authority over restaurants, but just last week urged them to promote healthier foods and give customers information on the nutritional content of what they're eating.

Write to Richard Gibson at dick.gibson@dowjones.com

Avoiding Tests Until It's Too Late
May 30, 2006

Some patients avoid tests at all costs.

Ed was one of those patients. Although he smoked at least a pack per day for 40 years, he stayed healthy enough to avoid needing a doctor's care for anything major since he was a kid.

He was never a fan of looking for trouble when he felt fine. He reasoned it was no use spending money he didn't have on screening tests he didn't need. He had insurance with a deductible, but he didn't use it.

He told his family that if he ever did get something bad, he really didn't want to know about it anyway. Ed beamed with pride informing me that he'd lost 25 pounds, after having been moderately overweight for years. He told me he just cut down on how much he was eating the last three months. He felt so much better that he decided to quit smoking and came in to see about some medication to help him kick the habit.

I was concerned because he looked pale and too thin. As I examined him, my heart sank as I felt the large tumor in his abdomen. Further testing showed colon cancer spread throughout his body. He opted for treatment, but died three months later.

It's thought that up to 80% of colon cancers are preventable, but Ed didn't get a screening test to check for it. I diagnosed him on his first visit. I never had a chance to bug him about getting screened. He avoided doctors for years; his daughter had been trying to get him to come in for a check-up for about a year. He had a family history of pre-cancerous colon polyps. I know his family history and continue to take care of his elderly mother, his daughter and several of his grandchildren.

I see people all the time who don't get screening tests for colon cancer, mammograms for breast cancer, Pap tests for cervical cancer or digital rectal exams for prostate cancer.

Some patients decline outright, many put things off and never get back to it until they come in to the office the next time. From a public health standpoint, patients like Ed who don't come in for any care at all are one of the biggest challenges.

Some avoid screening tests because of expense, inconvenience or perceived discomfort. Others don't know what screening tests are recommended, or they think that early detection of disease doesn't work. (Usually they are wrong -- detection does help; unfortunately, sometimes they are right and it doesn't.) Sometimes they shun tests because of the frustration with and fear of false positives.

At times people fear harm from the tests themselves. My partner spent nearly half of an annual exam visit recently trying to convince a 55-year-old woman that the small amount of radiation from a mammogram wasn't likely to give her breast cancer. She thought the risk of cancer from the mammogram was higher than her risk of getting breast cancer. Even when the doctor spent all the time in explanation, she still didn't go through with the test.

Getting someone to perceive a need and spend money and time on something they'd rather not do takes education and encouragement. In that way it's like the sales jobs I held to put myself through school, selling fitness club memberships and hardware at Sears. For now, salesmanship remains my main tool when it comes to screening tests. Patients need to be aware of what is needed and be proactive in asking their doctor for help. I see the doctor's job as notifying and tracking, and most doctors do an admittedly poor job on both counts. My dentist sends me a card for a cleaning every six months. But cleaning is a pretty standard thing for a dentist's patients. The primary-care doctor tracks multiple variables of different frequencies. For a 38-year-old healthy guy like me, we track 11 different health maintenance and screening items.

Tracking is a daunting job for a primary-care office, where we have patients of every age, with multiple conditions of varying severity. It involves integrating results from multiple providers of care. There's added staff time and expense to manage the process. I don't get paid for any of the behind-the-scenes work unless the patient comes in for the test. After figuring in staff time and computer costs, I'd be lucky to break even when a person does come in for screening.

Some insurers pay for screening, some don't, and some do only for certain conditions or certain time intervals. The workflow is complex and many electronic medical records don't yet make it easy enough.

It's my understanding that with the exception of a few pilot programs, commercial insurers, Medicare and Medicaid don't cover this added work outside of the traditional office visit. Few patients want to pay an extra annual fee to cover these additional services. If insurers want to compensate doctors based on performance, they can expect some doctors to drop patients that won't come in for follow-up or recommended screening tests.

I wish I had been a better salesman when I wasn't able to convince another patient to have his colon checked. His excuses were always work-related. One year he wanted to wait until the crops were harvested in the fall. The next year it was planting season and he didn't have time. The next year he didn't come in for a physical. The following year he came down with colon cancer.

When he was diagnosed with cancer he wanted to go 800 miles to the Mayo clinic to be treated at the cancer center, with no expense spared. Since his cancer started so low in his colon, I could have probably prevented his death with 20 minutes of his time and a $150 exam of his lower colon if he'd done a routine screening.

Health & Family
Aches & Claims: Ordering Up Your Own Medical Tests
By Robert J. Davis

09/17/2002
The Wall Street Journal
D4(Copyright (c) 2002, Dow Jones & Company, Inc.)

CURIOUS ABOUT your cholesterol but too busy to go to the doctor? A growing number of people are using direct-to-consumer lab services, which let you order your own blood and urine tests for everything from allergies to the AIDS virus. The process is quick and easy, but interpreting the results can be tricky without a doctor's help.

Several companies, including Quest Diagnostics Inc., HealthcheckUSA and Direct Laboratory Services Inc. offer direct testing. In some cities, you walk right into a testing facility and place your order. Usually, though, consumers log onto a Web site and choose from a menu of tests for disorders such as diabetes, Lyme disease, hepatitis and prostate cancer. You also can find out about kidney or liver function, check levels of calcium and other minerals and even screen for recreational drugs. Combinations of tests are offered, too, with names like "women's health profile" and "comprehensive wellness profile."

Customers are then directed to a lab in their area where the test is done. Results are sent via mail or e-mail, often within 48 hours. The price typically ranges from $20 to $150, though certain combinations can push it past $500. Insurance doesn't cover the bill. Because the results aren't sent to a doctor, they're not part of your medical record -- an advantage for those who want to protect their privacy.

Many states don't allow people to get medical tests without a doctor's referral. But testing providers often get around the law by having physicians on staff who approve all test requests, no questions asked. With each result, customers are given the range of normal readings, and if a result is way out of line, they may receive a letter urging them to see a doctor. Beyond that, testing services generally don't offer medical advice.

That's why it is a good idea to share the results with your doctor, especially if they are out of range. A reading that seems ominous could be a fluke or perfectly normal for you. And keep in mind that certain tests, including those for prostate cancer (PSA) and ovarian cancer (CA-125), are particularly prone to producing false alarms. At the same time, don't assume you are OK if the results are normal, especially if you have symptoms. Direct lab services are best used to monitor the effectiveness of a treatment (like thyroid medication), not for making a diagnosis.

Copyright © 2000 Dow Jones & Company, Inc. All Rights Reserved.

A long-awaited study of the popular arthritis supplements glucosamine and chondroitin was supposed to be the final word on the popular treatments. Instead, it has just reignited the debate over them.

Although the study didn't find any overall benefit to the supplements, many doctors don't think patients should give up on the treatments just yet. Some doctors reason that traditional arthritis pain remedies carry so many risks, the unproven treatments still might be worth a try. Many medical researchers, however, remain skeptical, saying it's unlikely the treatments have any effect at all.

Glucosamine, derived from shellfish, and chondroitin, made from cow cartilage, are among the most popular supplements on the market today, with combined sales in excess of $700 million. Many arthritis sufferers swear by the treatments, and a handful of studies, most of which have been sponsored by the supplement industry, have suggested the supplements really do help relieve arthritis pain.

The Glucosamine/chondroitin Arthritis Intervention Trial, or GAIT, was hailed as the largest-ever study of the supplements. The $12.5 million study was paid for by the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health. At first look, the results of the GAIT study, released in the New England Journal of Medicine last week, appear to debunk the notion that the treatments really work. In the six-month study of more than 1,580 arthritis sufferers, most of whom had mild to moderate arthritis pain, glucosamine and chondroitin didn't offer any more pain relief than a placebo pill.

But the study researchers and other experts say it's not time to write off the supplements. In a group of sufferers with moderate to severe pain, the glucosamine/chondroitin combination appeared to work. In that group, 79% of glucosamine/chondroitin users reported their pain had dropped by at least 20% after treatment. By comparison, only 69% of patients taking the popular drug Celebrex reported similar benefits. About 66% of patients taking glucosamine alone felt better, while 61% of taking just chondroitin felt better. That compares with about 54% of the placebo group who experienced some pain relief.

However, the study had only about 350 patients with moderate to severe arthritis pain. And then those patients were divided up into five separate groups taking various combinations of the supplements, Celebrex or a placebo. In the end, the part of the study with the most promising data was really only a study of 142 patients -- 72 taking glucosamine and chondroitin and 70 taking a placebo.

"I think the subgroup finding is a clinically important finding," says Daniel Clegg, the study's lead author and chief of rheumatology at the University of Utah School of Medicine. "But it should be interpreted cautiously."

Even so, Dr. Clegg says the results were promising enough that he plans to seek funding for another study looking directly at the effect of glucosamine and chondroitin on moderate to severe arthritis sufferers.

While it might seem like grasping at straws to focus on the results of such a small study group, the truth is, arthritis sufferers don't have many other options. In recent years, new health worries have emerged about popular prescription pain relievers, and one of them, Vioxx, was withdrawn from the market because it was linked with a higher rate of heart problems.

Long-term use of nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen, found in Advil, or naproxen, found in Aleve, is also highly risky. Each year, side effects from NSAIDs cause nearly 103,000 hospitalizations and 16,500 deaths. The drugs can lead to indigestion, peptic ulcer disease and damage to the small intestine and colon, resulting in internal bleeding, bowel perforation and other life-threatening problems. In one recent study comparing arthritis patients who used NSAIDs to those who used Tylenol or took nothing for pain relief, nearly 60% of NSAID users developed ulcers or erosions in the small intestine compared with 17% of nonusers.

Vijay Vad, sports-medicine specialist at the Hospital for Special Surgery in New York, says he is concerned the study results will prompt people to start using traditional pain relievers. "We have fewer options for treating arthritis today than we did five years ago," Dr. Vad says. "What I don't want happening is for people to switch over to anti-inflammatory drugs in giant numbers. I think there are positives in this trial that show these supplements are potentially valuable for a certain subset of arthritis patients."

Another reason researchers don't want to give up on glucosamine and chondroitin is that most arthritis treatments simply don't work that well for a lot of people. Notably, in one part of the GAIT study, Celebrex, a proven pain reliever, didn't offer significant pain relief for half the people who used it.

The supplements, which cost about $30 a month, are considered safe -- the main risk is for people who have shellfish allergy. As a result, doctors typically advise patients to use them for three months to see if they notice a difference. And if the subgroup finding from the study is to be believed, the biggest effect comes from taking both glucosamine and chondroitin, not just one.

In addition, the first GAIT trial isn't over yet. About half of the GAIT participants will be treated for an additional 18 months. Researchers will compare X-rays taken at the beginning of the study and after one and two years to determine if the treatments result in any noticeable changes in the knee joint. (No one knows exactly how the supplements work but they might have a mild anti-inflammatory effect or slow the erosion of joint cartilage.) Results are expected in about a year.

New data on estrogen show the risk of breast cancer is lower than previously believed and begin to answer questions about how long women can safely use the hormone.

The research, from Harvard University's Nurses' Health Study, is the latest piece of the increasingly complicated estrogen puzzle. The study looked at estrogen use among 28,835 nurses and whether long-term use affected risk for breast cancer.

The study showed there was no statistically significant increase in breast cancer risk with up to 20 years of estrogen use. But after 20 years of use, the risk of breast cancer jumped by 42%, according to the report published today in the Archives of Internal Medicine. The data also suggested that the breast cancer risk may be slightly lower during the first 10 years, but there weren't enough cancer cases among the women studied to make the number statistically reliable.

The data, which paint the clearest picture to date about how long a woman can use estrogen without increasing her risk for breast cancer, should be reassuring to the majority of women using hormones to relieve hot flashes and other symptoms of menopause. Of the 4.4 million U.S. women who use menopause hormones today, about 3.5 million take only estrogen. An additional 900,000 women take a combination of estrogen and progestin. (Progestin is added to blunt the effects of estrogen on the uterus and prevent endometrial cancer. Women take estrogen by itself if they've had a hysterectomy.)

Twenty years is far longer than most women today are advised to take hormones. Although duration of use varies, most doctors suggest women limit hormone use to less than five years.

But as many as 10% of menopausal women may still suffer debilitating symptoms for several years after menopause, requiring them to stay on the drugs longer. Other women who might require long-term use are those in their 30s and 40s who experience surgically induced menopause, caused by removal of their ovaries. To prevent a debilitating drop in estrogen, these women may need to stay on the drugs for 15 to 20 years until the time of natural menopause.

"This is reassuring to women who are contemplating taking estrogen alone for 10 to 15 years," says study author Wendy Chen, researcher at Brigham and Women's Hospital in Boston. "There are also a lot of women who went through menopause in the '70s and '80s who have been on estrogen for a long period of time. The question is should they still remain on estrogen?"

While the latest research is good news for most women using menopause hormones, it continues to raise questions about progestin and whether it's the real culprit in many of the health risks recently associated with hormone use. Studies have shown that using estrogen and progestin in combination is linked with a slightly higher risk of breast cancer after about five years of use.

The new data from the nurses' study are also consistent with a controversial finding of the government-funded Women's Health Initiative. The WHI reported in April that using estrogen for an average of seven years didn't increase the risk of breast cancer and may even have lowered it. The study shocked the medical community because it contradicted decades of earlier research that suggested estrogen was linked with a higher risk for breast cancer.

But one big problem with the WHI is that it was stopped a year early, because government health officials cited a slight increase in stroke risk among older women in the study. The WHI investigators lamented that year of lost data because it would have added credibility to the surprising finding.

Now the Nurses' Health Study has looked at the estrogen-breast cancer link for far longer than a clinical trial could ever do. The nurses study is an observational study that tracks the health habits of women over time without dictating any particular treatment. A clinical trial, like the WHI that compares a treatment to a placebo, is far more expensive to conduct for long stretches of time.

"There isn't ever going to be a clinical trial in which women will take estrogen for 15 or 20 years," says Dr. Chen. "It's a relevant question to women who are currently on estrogen, and they're deciding 'How long should I remain on it?'"

Most of the nurses' data before the 20-year mark didn't reach the point of statistical significance, meaning the findings could just be due to chance. The data showed that breast cancer risk was about 10% lower in the first 10 years of estrogen use, but the risk increased slightly over the next 10 years, but none of those findings were statistically meaningful because there were so few cancer cases among the women studied.

The 20-year mark was the first point in time when the data showed a statistically significant link with breast cancer. The investigators noted that among cancers that have hormone receptors for both estrogen and progesterone, which account for 44% of the cases studied, the risk for breast cancer increased sooner, at the 15-year mark.

Another important finding of the study showed that estrogen use for 20 years or more poses a higher risk to thin women than overweight women. The theory is that overweight women have more natural circulating estrogen from body fat, so hormones in a pill are less of a shock to the system than in a thin woman. The nurses' data showed that after 20 years of use, thin women had a 77% higher risk for breast cancer compared with thin women who didn't use hormones. Overweight women had a 25% higher risk after 20 years compared with overweight women who didn't use hormones.