Avoiding Neuropathy From Chemo; Predictive Value of Screening EKGs

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include avoiding chemotherapy induced neuropathy, predictive value of screening EKGs, use of medicines to treat opioid use disorder, and trends in cardiovascular disease (CVD) in the U.K.

Program notes:

0:40 Trends in CVD in 22 million people in the U.K.

1:40 Overall decrease in some by 30%

2:40 Atrial fibrillation most common now

3:40 Some associated with aging

4:22 Routine screening EKGs

5:22 Is an association with subsequent CVD

6:20 Does not imply routine screening EKG

6:40 Preventing chemotherapy-induced neuropathy

7:40 Two types of exercise and treatment as usual

8:41 Something that can be routinely done

9:40 Continuing exercise may help

10:14 Treatment for opioid use disorder

11:15 55% receive any treatment at all

12:15 Barriers as part of healthcare system

13:16 End

Transcript:

Elizabeth: Can we avoid chemotherapy-induced neuropathy?

Rick: Treatment for opioid use disorders.

Elizabeth: Trends in cardiovascular disease among 22 million people in the U.K.

Rick: And screening EKGs for cardiovascular risk assessment.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, I was quite interested in the fact that you did not choose this paper when I presented you with the studies for this week. This is in the BMJ and it’s a look at trends in cardiovascular disease incidence among 22 million people over the last 20 years.

They have, out of all those folks who were there, almost 2 million — 1.65 million people — who were part of their cohort with newly diagnosed cardiovascular disease between January 2000 and June of 2019. And they were looking at — and I’m gonna name them all; it’s a long list, but — diagnosis of cardiovascular disease, including acute coronary syndrome; aortic aneurysm; aortic stenosis; atrial fibrillation or what they call “flutter;” chronic ischemic heart disease; heart failure; peripheral artery disease; second- or third-degree heart block; stroke; or VTE — venous thromboembolism.

Among this cohort, their mean age was almost 71 years and slightly less than half of them were women. The standardized incidence of all 10 pre-specified cardiovascular diseases declined by 19%. They broke those out and saw that coronary heart disease and stroke decreased by about 30%. However, in parallel, they saw an increasing number of diagnoses of cardiac arrhythmias, valve disease, and thromboembolic diseases.

And so the upshot of the whole thing is that if you take the total of cardiovascular diseases, they remained relatively stable over this time period. While there was an observed decline in coronary heart disease, when they age-stratified that, they saw the folks who seemed to benefit were those older than 60 years of age with little or no improvement in the younger age groups. And that sounds like a not-great trend. And finally, they do note a socioeconomic gradient for almost every one of these conditions.

Rick: Some things got better and some things got worse, and atrial fibrillation is now the most common cardiovascular disease in the United Kingdom. Not only does it cause symptoms, uncontrolled heart failure is occurring in younger individuals.

OK, we spent decades trying to address some of the known risk factors to prevent diabetes and hypertension, and we’ve done a poor job of other things like obesity, sedentary lifestyle, drug use, alcohol use, things like that, that can actually increase the risk of atrial fibrillation, but allow us to focus our attention on the things that have worsened.

Elizabeth: One thing the authors point out is that some of the causes of some of these things that they’ve noted are really not known. They’re talking about aortic stenosis and heart block more than doubling over this study period, calling out for more research in these to figure out, “Well, all right, what are the underpinnings of that?”

Rick: The aortic stenosis, some of that’s congenital; 2% to 3% of individuals can be born with a valve that has two leaflets instead of three, but the other is usually just associated with aging, or with rheumatic heart disease. But that’s not usually an issue in the United Kingdom. So you’re right. There’s a lot we don’t know about that.

Elizabeth: I also just want to point out that, of course, men experience all of these things to a greater degree than women do, with the exception of VTE, which they note is similar in men and women. And I guess if we’re looking for reasons, I’d like to know the reason for that also.

Rick: Again, there are some risk factors that we’re aware of: obesity; sedentary lifestyle; smoking, we know increases that risk, as does treatment with estrogen or progesterone. A lot more we need to do in terms of digging underneath the hood to figure out why the incidence is going up in certain specific cardiovascular diseases.

Elizabeth: Moving on, then, which of your two would you like to turn to?

Rick: Elizabeth, since we’re talking about hearts, let’s talk about routine screening EKGs. It’s a nationwide study done in Japan. They looked at individuals who were aged 35 to 65. They were part of the Japan Health Insurance Association database — basically, that covers about 30 million of the working-age population in Japan.

When you go to work, one of the routine things that has to be done is a screening EKG. Now they have this information, is the EKG normal, or are there any abnormalities, either what are considered minor abnormalities — there could be 29 different ones of those — or major abnormalities? And they just follow these individuals for an average of about 5.5 years to say, “Are these EKG abnormalities associated with any type of cardiovascular disease due to heart attack or stroke or heart failure?” It’s about 3.7 million individuals that they’ve got EKGs on.

What they discovered is, oh, about a fifth of individuals have one or two minor abnormalities — less than 2% have a major abnormality. But there is an association with subsequent cardiovascular disease. In fact, it can go up from as little as 30% for one minor abnormality to almost double or triple for those that have a major abnormality.

When we look at the USPSTF [the U.S. Preventive Services Task Force], the European Society of Cardiology, and even the American Heart Association or the American College of Cardiology, they don’t recommend performing routine screening EKGs for individuals that are at low risk.

What were your thoughts about the study?

Elizabeth: They’re so ubiquitous, it seems to me we’re constantly being exposed to EKGs, and some analysis of whether that really yields anything that’s worth considering I think is good.

Rick: Yeah, ’cause here’s the question: what do you do with that information? Does it provide any additional information over the routine risk factors? This particular study didn’t really assess what we do with that particular information. And there’s always a concern that if you find a minor abnormality, it may lead you on a path where you’re doing stuff that’s not really helpful.

The editorialists and even the individuals that wrote the paper say, “This doesn’t imply that we should be doing routine EKG and acting upon it. It’s just another piece of information that we can use to assess what the risk is, and then more importantly, figure out later, well, what do you do with that information?”

Elizabeth: That’s in JAMA Internal Medicine. Since we’re there, let’s turn to another study that’s in the same journal. And this is looking at the preventive effect of neuromuscular training in chemotherapy-induced neuropathy.

This is a very important issue. It turns out that a lot of people will get this experience if they’re undergoing chemotherapy for cancer. It really depends, of course, on the agents that are selected in order to treat the cancer, but the likelihood is extremely high that neuropathy can develop in people who are treated with — in this study, what they look at is oxaliplatin or vinca alkaloids. And these are very commonly used.

They looked at 158 people, and they were randomized into one of three groups. About a third of them were in what they called sensory motor training; another group who were in vibration training, which is kind of an interesting thing; another third who were in treatment as usual. They did this training concomitant with their chemotherapy treatment, and then they looked at the incidence or the development of this chemotherapy-induced peripheral neuropathy.

Improvements were highest among those who had the sensory motor training compared to the vibration platform. Those compared very favorably with standard treatment group.

It turns out that there’s this huge argument for doing this, of course, because this is extremely corrosive to people’s lifestyles, the development of this type of neuropathy, and it also increases their risk of falling and having subsequent injuries. So these authors say, “Yup, initial evidence that neuromuscular training can decrease chemotherapy-induced peripheral neuropathy.”

Rick: This is really an important study, in my opinion, because as you mentioned, with certain types of chemotherapy, as many as three-fourths of individuals will develop neuropathy — and we’re talking about there’s tingling; they can’t feel; frankly, it could be even burning. Not only does this affect the quality of life, and as you mentioned, increase the risk of falls, but sometimes it limits the amount of chemotherapy they can receive, so they don’t get the full benefit of it.

This is a remarkable study in that we’re talking about something that can be routinely done: exercise, balance exercises, that were performed approximately 15 to 30 minutes twice a week over a 4-month period. This showed that it decreased the neuropathy over the 4 months that they received the exercise.

Unfortunately, if you look 6 or 7 months down the road, the difference between that and routine therapy starts to narrow. It could be that it doesn’t really stop the neuropathy — it delays it; that’s one possible explanation. The other is you may just need to do it for a little bit longer.

And they’re talking about how it works in that it’s neuro-regenerative: the exercise decreases inflammation, increases the regeneration of the nerves and what’s called neuroplasticity.

Elizabeth: You’ve identified this notion that the thing to do is to continue to do it, and I learned a new word in here. It’s “coasting,” and that’s the phenomenon in which this peripheral neuropathy can develop or worsen for 2 to 3 months following chemotherapy completion. So keeping going on this exercise is a really good idea.

The editorialist also notes that the median age of the folks in this trial was 49 years, and that’s a young group. They question whether in older people in whom cancer is much more likely to develop would experience the same benefits. In my mind, however, well worth studying it and seeing.

Rick: Absolutely. So you mentioned two studies are going to be done in the future. One is extending this to older individuals, and then extending the duration of the exercises.

Elizabeth: I agree. Well finally, let’s turn to MMWR.

Rick: Treatment for opioid use disorder. We know in 2022, there were almost 82,000 opioid-involved overdose deaths in the United States. That’s more than has been reported any previous year. We now know that’s usually due to fentanyl overdose, and oftentimes, these are occurring in individuals that don’t realize they’re getting drugs that are laced with fentanyl.

There’s about 3.7% of the U.S. population that has an opioid use disorder and should receive treatment. Treatment can be pharmacologic, or non-pharmacologic. Medicines are particularly useful — basically three: buprenorphine, methadone, and extended-release naltrexone. The first two are especially helpful; they reduce overall and opioid-related mortality.

How often are people with opioid use disorder actually receiving them? Really a very small proportion of patients with opioid use disorders specifically get it; 55% receive any type of treatment at all, and 25% actually received medications.

Most adults who needed the treatment either did not perceive that they needed it; they thought, “Oh, I’m doing fine. I don’t need it.” That was about 43%. Or they received treatment that did not include medications at all — that was about 30%. We have a lot of work to do.

Elizabeth: Any notion on why this happens? What are the barriers for the purveyance of treatment?

Rick: Individuals that were thought to have the most severe opioid use disorder, OUD, were a little bit more likely to receive it than those that had a mild or moderate. Either the individuals thought, “Well, I don’t really need it because it’s not that severe” or the healthcare providers didn’t provide it.

Second is lack of access. Until recently, administration of these medications required physicians to be certified. That’s been relaxed a bit. But nevertheless, there are a lot of physicians that don’t feel comfortable doing it.

Lastly, it’s drawn along socioeconomic status. Even though there may be individuals that are trained or certified or comfortable with them, there are many individuals that just don’t have access to these individuals.

Elizabeth: I guess I’m the most interested in what are the barriers that are in place in our healthcare system that are precluding the ability of these people to access treatment?

Rick: Too little experience treating this. Physicians are actually concerned about being inundated with requests, and they don’t feel like they want to take it on. I mentioned there’s lack of access specifically to addiction or behavioral health specialists.

Elizabeth: And I guess this begs the question of should we establish some kind of training cohort who would be able to provide this kind of treatment but don’t necessarily have to be physicians?

Rick: That’s a good point. I mean, if we can extend access to individuals, either through physicians or health extenders, that should make it more available to individuals.

Elizabeth: On that note, then that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.