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The Justice

And then the justice...full of wise saws and modern instances

As Shakespeare observed, mid-life is a time of many changes – in mind (“full of wise saws”) and body (“in fair round belly”). By their middle years, many people have been in the same situation, the same relationship, the same job for a long time. “They typically start to re-evaluate their lives,” says Dr. Brian Baker, an associate professor in the department of psychiatry. “They start to wonder, ‘Is this all there is?'”

Certain physical changes normally start to occur in the 40s and 50s: menopausal symptoms in women and sexual changes caused by declining testosterone levels in men. Many suddenly can’t read a phone book without glasses. And as they approach 50, some report being more forgetful.

In most cases, these turn out to be benign signs of fading youth rather than symptoms of serious health problems, says Dr. Baker. More serious cause for concern are mid-life developments such as high blood pressure and high cholesterol, both risk factors for heart disease and stroke. “There’s a whole host of problems that, statistically speaking, people are vulnerable to, even if it’s to a minor degree. In some people, this is when a major disease develops,” says Dr. Baker.

So what is the best way to approach the many changes and challenges of middle age? “It’s important to be aware of what’s going on both physically and emotionally,” says Dr. Baker. “People should see their doctor at least once a year, because some risk factors need treatment, and sometimes illnesses show themselves early. This is the time for PSA [prostate-specific antigen] blood tests that may help detect prostate cancer, for regular colonoscopy [to detect colon cancer] and for breast examinations.”

According to the Heart and Stroke Foundation, the greatest threat to middle age is heart disease and stroke, which kills approximately 79,000 Canadians each year. Classic risk factors, such as high cholesterol, diabetes, high blood pressure, smoking and family history, account for only about 30 to 50 per cent of these diseases, says Dr. Peter Liu, holder of the Heart and Stroke/Polo Chair and director of the Heart and Stroke/Richard Lewar Centre of Excellence. Dr. Liu and his colleagues are working to identify so-called “novel” risk factors – other possible causes of cardiovascular disease such as bacterial or viral infection. One example is chlamydia pneumoniae, a common bacterial infection. “By the time we’re 50, about 80 per cent of us have had exposure to this bacteria,” says Dr. Liu. There’s evidence that chlamydia may infect blood-vessel walls, adding to a build-up of fatty substances (atherosclerosis) that causes blood vessels to narrow dangerously.

Researchers are now working to understand how chlamydia gets into blood vessels, and to what extent this contributes to heart disease. They are also investigating whether antibiotic drugs or even a vaccine against chlamydia might one day protect people from heart attack and stroke.

As we age, most of us also start worrying about cancer. Lung cancer is now the leading cause of cancer deaths among Canadians of both sexes. According to recent statistics, more than 17,000 Canadians died of lung cancer in 1998. “There’s no question that smoking has had a major impact on lung cancer rates, especially in women,” says Dr. Ron Feld, a medical oncologist at Princess Margaret Hospital in Toronto and a professor of medicine at U of T. When he began treating cancer patients 30 years ago, he says lung cancer patients were overwhelmingly male. But as women began to smoke tobacco, their rates of lung cancer began to “catch up.”

If caught early, lung cancers are quite survivable, says Dr. Feld. But until recently, doctors had no really effective tools for early detection. A special type of computed tomography or CT scan, called spiral CT, is now being tested to see if it might help pick up earlier, more curable lung cancers.

Overall, cigarette smoking is the primary cause of lung cancer, accounting for at least 80 per cent of new cases in women and 90 per cent of those in men. Dr. Feld says current smokers can reduce their risk for lung cancer – and also for various head and neck cancers, bladder cancer and heart disease – by doing whatever it takes to give up tobacco.

Among women, the most frequently diagnosed malignancy is breast cancer, which is more common after age 50. Researchers continue to explore early-detection options. A recent study by epidemiologist Dr. Cornelia Baines and colleagues at U of T compared the effectiveness of an annual mammography (breast X-rays) plus a clinical breast exam (CBE) with CBE alone in women aged 50 to 59. CBE involves a specially trained doctor or nurse inspecting the breasts for abnormalities.

“Mammography detected more cancers and picked up smaller cancers than CBE,” says Dr. Baines, a professor in the department of public health sciences and deputy director of the Canadian National Breast Screening Study. “But after 13 years of followup, mammography had not reduced deaths from breast cancer.”

This research establishes that CBE may be an effective choice for women who don’t have regular mammograms, adds Dr. Baines. CBE may be especially useful for women aged 40 to 49, because mammography is less accurate in younger women than in older women.

The major concern for men is prostate cancer. While much research has focused on earlier diagnosis and better treatment, Johanna Rommens, an associate professor of molecular and medical genetics, is working to provide more information about prostate cancer risk.

Dr. Rommens has been part of an international research team that has discovered a new genetic footprint for prostate cancer: earlier this year, scientists reported finding two different mutations – high-risk and moderate-risk – of a gene called ELAC2. Men carrying the high-risk version were five to 10 times more likely to develop prostate cancer than those without this mutation; those with the moderate-risk version were 1.5 to three times more susceptible. Although this finding won’t lead to an immediate genetic test for prostate cancer, Dr. Rommens says, it does provide momentum for further research.

Making choices for menopause
Confused about the alternatives to hormone replacement therapy for relieving menopausal symptoms and reducing the risk of heart disease and osteoporosis? You’re not alone.

U of T researchers are currently studying hormone replacement options known as selective estrogen receptor modulators, or SERMs. “These are compounds that are like hormones, but very specific for various organs,” explains Dr. Angela Cheung, assistant professor in the departments of medicine, public health sciences and health policy, management and evaluation.

Dr. Cheung and Dr. Donna Stewart, professor and chair of women’s health at the University Health Network and University of Toronto, are currently involved in a seven-year international study of the effect of a particular SERM called raloxifene on heart disease. The RUTH (Raloxifene Use for The Heart) trial, involving 10,000 women around the world, is still about five years from completion. Dr. Cheung also took part in a recently published study that found that raloxifene increased bone density only modestly (two to three per cent), but significantly decreased spine fractures (35 to 55 per cent).

SERMs may cause hot flashes, so they may not be the best choice until after menopause, says Dr. Cheung. Menopausal women wanting to protect their heart and bones should first consider exercise, good nutrition and quitting smoking.

Early detection of bone disease
Unless you’ve broken an ankle on the ski slopes, you probably haven’t given much thought to your bones. But bone health becomes important in middle age: according to the Osteoporosis Society of Canada, one in four women and one in eight men over 50 have osteoporosis, a disease in which bones lose mass and become more fragile and prone to fractures.

“Many end up with a fracture, then another fracture, and keep going to a fracture clinic but never seem to get diagnosed and treated for osteoporosis,” says Dr. Rowena Ridout, staff physician at Women’s College Hospital and an assistant professor in medicine, adding that so-called “low-trauma fractures” are often the first sign of osteoporosis. These fractures typically occur after a non-serious injury, or a fall from a standing height or lower, and often affect the wrist, hip or spine. People over 50 who experience such a fracture should investigate the possibility of osteoporosis with their doctor.

Bone density scans can help with diagnosis and treatment, which may include taking a bisphosphonate drug such as Fosamax (alendronate) or Actonel (risedronate). These drugs slow down the resorption or loss of bone that leaves bones fragile, Dr. Ridout explains.

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