Rural doctors in China; Free cancer screening; New TB vaccine; Do doctors have good cardiac skills?

by MICHAEL WOODHEAD

In a sign of the increasing concern about the demise of rural healthcare, China's 1.4 million rural doctors have now been given their own professional organisation.
Although it's not quite a trade union, the Chinese Medical Association has established a rural doctors section that will represent the interests of the many village doctors. The move is in response to the ageing of the semi-skilled workforce, most of whom lack medical degrees and have only high school education and a short training course on healthcare provision. According to the CMA, the new Rural Doctors Association "will assist the government to strengthen and promote rural doctor team building for the survival and development of rural medicine and safeguard the legitimate rights and interests of rural doctors."
Earlier this year Premier Li Keqiang acknowledged that it was important to retain doctors in rural areas, because their primary care role was "more effective than building a large hospital." The State Council acknowledged that rural doctors were the cornerstone of primary healthcare for hundreds of millions of rural residents.
However, most rural doctors are approaching retirement and younger people do not want to work in remote 'backward' areas in a role that is poorly paid and has few career prospects. Rural doctors by decree are paid the same salary as rural teachers - which is a pittance.Their miniscule pensions are an even greater cause for complaint.

Free screening programs for breast cancer and cervical cancer are to be developed nationally in China, according to the National Health and Family Planning Commission. The ministry said 48 million women in rural China had already received cancer screening interventions since 2009,  and there were now plans to increase promotion of screening services, co-ordinated by the All-China Women's Federation.

Despite studying medicine for seven years, China's junior doctors are unable to manage the basics of dealing with a heart attack, a study shows. A survey of 362 new medical graduates found they had little knowledge about basic cardiac diagnosis and resuscitation. Only about 50% of the doctors were able to identify common normal and abnormal ECG changes such as ventricular fibrillation. Likewise only half knew the basics of which drugs should be given for such conditions. The findings showed that many medical graduates were unprepared to manage the most common cardiac emergencies said researcher Dr Xi Huijun and colleagues from the Changhai Hospital, Shanghai.

China is leading the world in developing a new TB vaccine to replace the largely ineffective BCG vaccine against tuberculosis. At a TB vaccine conference held in Shanghai, researchers heard that a vaccine called Vaccae developed by an Anhui pharmaceutical company is in Phase 3 trials, whereas other candidate vaccines from other countries are only in the preliminary stages. Researchers said the vaccine would probably of most use in the elderly, who are expected to account for more than half of tuberculosis cases in the future.

Research fraud and inappropriate treatment: my blog about medical news from China for Sunday 15 February.

Last week I blogged about how so many medical journal articles in China are simply "vanity publications", written by ghostwriters to satisfy the doctor's need to achieve a quota of published articles. However, this week we see that there are also major problems with 'serious' research clinical trials carried out in China. An article in JAMA this week by Charles Seife reveals that the FDA found serious problems with the Chinese clinical trials of apixaban, a novel anticoagulant.
 At one site the FDA concluded that patient records had been altered. When they investigated further the FDA inspectors declared that data from 23 other Chinese clinical trial sites was suspect and should be excluded from their evaluation of apixaban (Eliquis). We often hear that western pharma companies are shifting their R&D from the US and Europe to China. It may be cheaper but with reports like this you have to wonder if it is worth it in the long run.

China is also trying to make a name for itself in high tech areas such as stem cell transplantation. An announcement in the Shanghai media said the city was to build the world's largest hospital for 'blood diseases'. This seems to be a reference to  hematopoietic stem cell transplant procedures for patients with blood diseases such as leukaemia. This is a highly specialised and expensive form of treatment for a small niche of patients (and often of limited benefit), so it is odd that a city that can't even meet demand in its emergency departments  is pushing ahead with a hospital for rare diseases. perhaps the explanation is that the project is being run by the China Stem Cell Group Co Ltd. This may be more about making profits than providing needed health facilities.

China's love of high tech for its own sake is  also manifest in the move by a Guangdong hospital to set up 1000 telehealth stations in pharmacies to provide online consults. The move by the Second People's Hospital of Guangdong to set up the Guangdong Online Hospital will reportedly include 200 doctors providing services via videolink. All sounds very modern, but how exactly does a doctor do a physical exam, order tests and imaging and provide 'hands on' care over a video link? It might be of limited value in follow up counselling consultations and for repeat prescriptions, but it sounds like a gimmick to me.

Online hospitals are supposed to help address the problem of overcrowded hospitals. I'm not sure how they will help the cancer patients who need a bed but can't get one. In places such as Changsha in Hunan the hospital bed shortages are so acute that patients have to make do with 'cancer hotels' instead. Patients with cancer who require treatment but who are on the waiting list pay 1100 yuan a month to stay in hotels adjacent to the cancer hospitals so they can go into outpatients for treatment. Locals say that about half the hotels near the hospital are occupied by patients, who face 1-2 month waits for a bed.

Breast cancer is an increasing concern in China, but rates are still not as high as in the west, perhaps due to dietary and lifestyle factors. Screening for breast cancer is also not part of the Chinese health system, although there has been some use of mammography. However ultrasound has been favoured by some Chinese clinicians, reportedly because it is more suitable to the smaller and more dense breast tissue of Chinese women. Now a study has confirmed that ultrasound is a more effective screening method for breast cancer in Chinese women. A study of more than 12,500 women who underwent either or both found that of the 30 cancers detected, five were in the mammography group and 11 in the ultrasound group, and 14  in the combined group. Ultrasound was more sensitive had the same specificity and positive predictive value as mammography. It was also considerably cheaper, costing $7876 to detect one cancer compared to $45 253 for mammography.

In other clinical news, metabolic syndrome (a highly dangerous combination of abnormal cholesterol, high blood pressure and pre-diabetes) was found to occur in 27% of Chinese people. A study of 15,477people in NE China found that 28% of men and 26% of women had metabolic syndrome. The condition was more common in Chinese on high incomes, those who ate more rice and those who did less physical activity - in other words, 'to get rich is glorious' but it also comes at a price of this disease of affluence. 

However, Chinese people might be forgiven for thinking twice about going for a jog, given the terrible air pollution in many cities. This has now been confirmed by Dr Liu Yu of the Key Laboratory of Exercise and Health Sciences at Shanghai University of Sport. This week he published an article in the BMJ which warned that the harms of ambient air pollution on the cardiovascular and respiratory systems might outweigh the benefits of exercise. He estimated that air pollution probably caused more than a thousand deaths a year in the city.

It's not all bad news from China, though. A paper published by the WHO this week shows that Chinese healthcare workers have had great success in reducing deaths from HIV using a simple 50c antibiotic, co-trimoxazole. Their study showed that giving the antibiotic at the same time as antiretroviral reduced HIV deaths by 37% - a staggering achievement. If routinely use in China for HIV patients  this could save thousands of lives among HIV positive people, the researchers sai.d Unfortunately, however, antibiotic use if often missed in this patient group.

Breast cancer with Chinese characteristics

by Michael Woodhead
Breast cancer rates in Chinese women are only one sixth those of their American counterparts, but China is catching up quickly, a new report says.
A review of breast cancer in China published in the Lancet Oncology this week shows that breast cancer has traditionally been an uncommon disease in China but rates are increasingly rapidly as the country adopts more affluent lifestyles.
The report by researchers at the National Office for Cancer Prevention and Control, Chinese Academy of Medical Sciences, Beijing shows that more than 1·6 million Chinese people are diagnosed with breast cancer and 1·2 million die of the disease each year. Breast cancer is now the most common cancer in Chinese women, accounting for cases 12% of all newly diagnosed breast cancers. Annual incidence rates are about 22 per 100,000, compared to rates of around 120 per 100,000 in the US.
The reviewers say breast cancer occurs at a younger age in Chinese women compared to their western counterparts, and for this reason screening programs such as mammography would probably not be appropriate. Rates have increased in recent years due to reproductive factors such as the single child policy and later age of first birth increasing exposure to sex hormones.
For these reasons, and because of the low awareness and delays in diagnosis, Chinese women with breast cancer tend to have more advanced stages of disease when diagnosed.
Another major disparity with breast cancer in China is the lack of adequate treatment. Most women cannot afford the more expensive advanced drugs for breast cancer now recommended in international guidelines. Paradoxically, treatment of breast cancer by Chinese doctors tends to be over-aggressive, with excessive surgery and chemotherapy. Many women have unnecessary mastectomy and axillary lymph node dissection and also chemotherapy. Under-treatment is also common, with some women receiving inadequate therapy for treatable cancers. The reviewers say palliative-care programs probably represent the best way forward to manage quality of life for patients with advanced disease and their families.
They conclude by saying there is a need for more public  awareness of breast cancer and promotion of early detection.
"Because the disparity of access to treatment for breast cancer will remain for some time, great effort is needed to expand insurance benefits and cancer-care infrastructure to underserved women in China," they conclude.

Three out of four Chinese women have never had a mammogram

by Michael Woodhead
Breast cancer incidence has increased dramatically among Chinese women in the past 20 years most have never had a mammogram and have little interest in undergoing screening, a new study has found.
A survey conducted in 400 women in Wuhan flu d that 75% of the women never had a mammogram. Most women felt that there was little need to have breast cancer screening, especially if they were healthy, and many showed a lack of awareness and knowledge of breast cancer screening.
The study researchers said that the changes in breast cancer incidence and distribution of breast cancer patterns in Chinese women present opportunities for developing and implementing effective public health programs to promote breast cancer screening for women in China.
"It is essential that public health campaigns focus on the importance of early detection and prevention that target both general public and health care professionals working directly with their clients," they say.
They note that the concept of screening while asymptomatic is lacking among Chinese women and a low priority toward breast cancer screening was observed in the study.
"As a result, this study highlights a critical need among general public, health professionals, and the health care system to work collaboratively toward narrowing the gap in breast cancer screening and to improve the quality of breast cancer care in this population.
Source: International Journal of Breast Cancer

Breast cancer more aggressive and has earlier onset in Chinese women

Breast cancers have a younger age of diagnosis in China

 by Michael Woodhead
Screening for breast cancer in China may need to start earlier because breast tumours are more aggressive and strike earlier than in western countries, Beijing clinicians say.
Researchers from the Department of Pathology at the Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College analysed the pathologic character of female breast cancers treated in seven tertiary hospitals in China between 1999–2008.
They found that on the whole breast cancers in Chinese women were similar in character to those seen in other Asian countries. However, breast cancers in Chinese women showed a younger age at diagnosis, larger tumor size, later tumor stage, than those typically seen in western countries, the researchers found.
They say the  lack of breast cancer screening in China might explain some of the difference as this would reduce the chance of early diagnosis.
Apart from  environmental and social economic factors, the differences of pathological features and biological markers between the Western and Chinese population may also reflect the magnitude of background breast cancer risk and differences in genetic background such as oestrogen receptor alpha gene polymorphisms.
"Our results suggest that Chinese women need breast cancer screening at an earlier age and that Chinese invasive breast cancer may be more aggressive than in western counterparts and need more specific therapeutic models," they conclude.
"Our study provides new findings showing that breast cancer can vary between different ethnic populations due to the magnitude of background breast cancer risk, genetic and/or environment discrepancies. We also [show] the urgent need to employ race-specific breast cancer screening, diagnosis methods and therapeutic models in China."
Source: International Journal of Cancer