Health Tip: Could this skin lesion be cancerous? Part 1

Skin cancer is the most common form of cancer in the United States, occurring in over two million people each year.  Three of the most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Each has characteristic features that can help alert you to the possibility that you may have developed a skin cancer.

Squamous cell skin cancers (SCC) arise from squamous cells which comprise most of skin’s outer layer (epidermis).  Since these are often related to UV exposure from the sun, they most commonly develop on the face, ears, arms or hands.  In their earliest form, they often appear as rough, scaly, red patches.  Unlike a skin rash that may fade with time, however, these rough patches persist and continue to progress slowly. Over time, they may become crusted, bleed, or develop an indentation in the center of the lesion. On occasion a SCC may have a wart-like appearance.

Approximately 40 to 60% of squamous cell skin cancers begin as a pre-malignant lesion known as an actinic keratosis (AK). Also known as solar keratosis, these develop on sun-exposed areas of the body such as the face, arms, backs of hands, and lips. An AK is usually rough in texture, resembling a wart, and may be felt before actual changes of the skin are noted. Their color can range from flesh-toned to brown or red. Most are small, less than a half inch across. Approximately 10% of AKs progress to become squamous cell skin cancer.

Basal cell carcinoma (BCC) develops in the basal cell layer of the skin, the deepest layer of the epidermis. It is the most common type of skin cancer occurring in the U.S.  BCCs are usually seen in areas of the body that have been exposed to the sun, such as the face or arms. Warning signs that should alert someone to the possibility of a BCC include:

• A persistent open sore that bleeds or oozes. On occasion, these may appear to heal only to re-open and bleed again.

• A pearly bump or nodule that may be pink, red, or white. Small blood vessels may be apparent on the surface.

• A lesion with a crater-like appearance with elevated border and indentation in the center.  

•  An area of skin that is shiny and tight like a scar that develops without injury.

Melanoma is a cancer of the pigment producing cells (melanocytes) of the skin. The great majority of melanomas can be attributed to exposure to ultraviolet (UV) radiation from the sun.  Melanoma begins on the surface of the skin but over time can extend deeper and in some cases, even spread throughout the body. Signs indicating that a skin lesion could be a melanoma include new pigmented area on the skin, or a change in size, shape or color of an existing mole. The ABCDE rule is another way to recognize melanomas:

• Asymmetry: A mole that has an irregular shape, or the shape of one half does not match the other half.

• Border: The edges are often irregular, blurred, rough, or notched in outline.

• Color: Most moles are evenly colored, e.g. brown, black, or tan.  Changes in the shade or distribution of color throughout the mole can signal melanoma.

• Diameter: Moles larger than ¼ inch (6 mm, the size of a pencil eraser) across are suspicious.

• Evolving: The mole has changed over the past few weeks or months

Regular examination of the skin, by a physician or by self-examination, is the key to identifying skin cancers in their earliest stages.  Any suspicious lesion should be brought to the attention of your primary care doctor or a dermatologist. Next week we’ll look at how these common forms of skin cancer are treated and learn the best ways of preventing skin cancer.

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Health Tip: Lipoprotein A - The Bad Cholesterol You Can Inherit

The New York Times recently featured a story on Bob Harper, a celebrity fitness trainer for the hit TV show, "The Biggest Loser." He is extremely fit and healthy, and yet had a massive heart attack at age 52. As it turns out, he has a fairly common genetic condition (it is estimated that 1 in 5 Americans have it) in which his body produces too much lipoprotein(a), a type of "bad cholesterol" that promotes blood clots and inflammation, affecting the heart.

It's rather surprising that 20% of Americans have a condition that predisposes for early heart attacks, and yet we don't regularly test for the condition. Why is that? The American Heart Association offers a few explanations: First of all, there is no affordable, widely-available medication available to treat high levels of lipoprotein(a). There are some very expensive monoclonal antibody drugs on the horizon, but they are still undergoing testing and are not widely available or covered by insurance. Niacin may be useful in treating high lipoprotein(a) but clinical trials have not shown a reduction in heart attacks even though it may lower blood levels of the bad cholesterol.

Secondly, lipoprotein(a)'s function in the body is not fully understood, and preliminary studies suggest that very low levels of it, as well as very high levels of it, may be bad for your health. And thirdly, since we don't have consensus about what levels are ideal, and doctors aren't sure what to do with a positive test result, there is understandable hesitation in testing for it. Nevertheless, one thing is certain: high levels of lipoprotein(a) are an independent risk factor for heart disease.

Since your total risk of heart disease increases with every independent risk factor that you have, it makes sense that current recommendations are to lower your overall risk, especially if you have high lipoprotein(a). This includes lifestyle interventions such as regular exercise, maintaining a healthy weight, eating a Mediterranean diet, limiting alcohol intake, reducing stress, quitting smoking, as well as medical options -  taking a cholesterol-lowering statin (such as Lipitor), low dose aspirin to reduce blood clotting, and keeping tight control of your blood pressure and diabetes (if you have them).

If anyone of your close relatives had a heart attack before the age of 55, you may be at higher risk for one as well. Take special care to reduce as many risk factors as you can control and ask your doctor if you may be a candidate for further testing or treatment. It's likely that lipoprotein(a) analysis will become more common in the future. Unfortunately, with unfavorable genetics, even the fittest among us can't reduce our risk of a heart attack to zero. Just ask Bob Harper.

References
https://www.nytimes.com/2018/01/09/well/heart-risk-doctors-lipoprotein.html
http://www.lipoproteinafoundation.org/?page=UnderstandLpa
http://jaha.ahajournals.org/content/5/4/e003597
http://www.heart.org/HEARTORG/Conditions/HeartAttack/LifeAfteraHeartAttack/Lifestyle-Changes-for-Heart-Attack-Prevention_UCM_303934_Article.jsp#.Wl5_CainGHk

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Health Tip: Do You Need A Multivitamin?

Most of us presume that taking a multivitamin every day is a good idea. "Can't hurt, might help" is what we think. And because many of us struggle with getting in enough vitamin-rich fruits and veggies, surely a little supplement is a reasonable "plan B." In fact, roughly one-third of American adults take a multi-vitamin.
Well, the answer to whether or not you need a multivitamin is a little bit complicated. First of all, most Americans get sufficient amounts of nutrients from their (albeit sub-optimal) diets that they are not vitamin or mineral deficient in any clinically significant way. Many years ago vitamin and mineral deficiencies (such as vitamin C - which causes scurvy when absent from the diet, vitamin D - which causes soft bones or rickets, iodine - now added to table salt - can cause thyroid disease or goiters) were a serious public health threat. Nowadays, these diseases are rarely seen in the doctor's office.

That being said, years of research suggest that certain vitamins and minerals are important to supplement under specific circumstances. It would take many book chapters to provide yo
u with all the details and nuances, but I'll try to summarize the most important points here for you.

• Over 65 years old: As we age, vitamin and mineral deficiencies become more common. Vitamin D, Zinc, and Vitamin B12 are the most common deficiencies in seniors. Vitamin D supplementation is now recommended to improve strength and balance in people over 65. Supplementation has been shown to reduce falls by 19%.
• Age-Related Macular Degeneration: Those with this particular eye health issue may benefit from vitamin supplements rich in lutein, beta-carotene, Vitamins A, C, E, and minerals zinc and copper. Eye health supplements are commonly known under the trade names Ocuvite and PreserVision and may reduce the risk of vision loss as you age.
• Malnutrition: If you are eating limited nutrients (either due to extreme dieting, veganism, or perhaps a medical problem such as stomach ulcers or cancer for example) then there is a greater chance that you have vitamin or mineral deficiencies. Those with poor calorie (or poor food quality) intake should ask their doctor if vitamin or mineral supplementation is needed.
• Wound Healing: Large wounds (from accidents, burns, surgeries or diabetic ulcers, etc.) heal faster if additional vitamin A, C, E and Zinc are supplemented.
• Pregnancy: If you are pregnant or trying to get pregnant, you should definitely supplement a healthy diet with a pre-natal vitamin that includes folic acid, iron, iodine, and calcium.
• Chronic anemia or recent blood loss: If you are anemic due to iron deficiency, iron supplementation is appropriate. Keep in mind that oral iron causes significant constipation.
• Gastric Bypass: If you have had gastric bypass, your absorption of nutrients is likely impaired. Although Vitamin B12 levels are most commonly affected after gastric bypass, folate, zinc, copper, calcium and vitamin D may also be impacted.
• Heavy Alcohol Use: Folic acid and vitamin B1 and B12 may be low and require supplementation in those who drink alcohol heavily and regularly.

Can a multivitamin do harm?
It's important to know that the Food and Drug Administration (FDA) regulates dietary supplements under a different set of rules than those covering "conventional" foods and drug products. Therefore the contents of multivitamin containers are not independently verified or tested by the US government. It is possible for vitamin companies to sell vitamins and minerals that contain more or less of what is listed on the label.
Quality vitamin and mineral manufacturers voluntarily submit to careful oversight by one of 4 independent companies, and will display their seals (for example US Pharmacopeia, USP, or Consumer Lab) on the bottle.

If your multivitamin causes you to exceed the recommended daily allowance for various vitamins and minerals, you could be at risk for serious side effects. A few examples include:

Calcium - Long term over-supplementation with calcium has been associated with higher rates of heart attacks. The theory is that while calcium is good for the bones, the body may store excess calcium in the walls of heart arteries, causing them to narrow and eventually close.

Vitamin A - High levels of vitamin A can cause symptoms such as nausea and hair loss, and may increase the risk of lung cancer for smokers. There is a risk of birth defects when pregnant women take too much vitamin A.

Iron - In excess, iron can be toxic. Nausea, vomiting, and diarrhea, may progress to seizures, double vision and a rapid heart rate. Iron overdosing is especially dangerous for children.

Manganese - In excess, manganese can cause headaches, muscle cramps, fatigue, and aggressiveness which can then proceed into tremors

Conclusion: Most healthy Americans do not need to take a multivitamin. Specific vitamins and minerals contained in a multi-pill may be helpful when deficiencies are present, but food sources are generally better absorbed. If you have a specific deficiency, supplementing only that vitamin or mineral may be safer than taking a pill that includes more than you need. Look for safety and quality seals of approval from reputable organizations such as Consumer Lab or USP for additional assurance that the vitamin and mineral labels accurately represent their contents.

References
https://ods.od.nih.gov/factsheets/MVMS-HealthProfessional/#en36
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4217039/
https://www.sciencedaily.com/releases/2009/10/091001191659.htm
https://www.ncbi.nlm.nih.gov/pubmed/17209218?dopt=Abstract
https://www.mayoclinic.org/drugs-supplements/iron-supplement-oral-route-parenteral-route/side-effects/drg-20070148

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