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INSIDE HEALTH

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TX:Ìý 05.02.13Ìý 2100-21300

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Hello and welcome to Inside Health - coming up today:Ìý Something old…

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Clip

We've scanned the skeleton that was dug up in Leicester recently by the archaeology department, so Richard III has been on the scanner.

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And did you find the cause of death?

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We did yes.

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And what was that?

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Well it was fairly obvious - there's a large hole in his skull, so I think that's probably what killed him.

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Porter

And something new: ÌýI meet the team pioneering a high tech alternative to post mortem examinations.Ìý It may have helped confirm how King Richard died, but what's in it for the rest of us?

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Also, cancer and your family - at what stage does a family history of cancer start to have serious implications for your health?

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And so called chemo-brain - we investigate a listener's concerns about the effects of chemotherapy on memory and intellect.

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But first, questions about the effectiveness of one of the mainstays of drug safety in the UK - Yellow Cards.Ìý The scheme - which depends upon healthcare professionals and the public using the yellow form to report suspected side effects -ÌýÌý is used by the Medicines and Healthcare Products Regulatory Agency to monitor the safety of medicines and vaccines. But it only works if people make the effort to report their concerns, and the latest statistics suggest the scheme might be withering on the vine.

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Reports from GPs have been falling for a decade - just over three and a half thousand last year down around a third from 2003.Ìý Not many considering there are over half a million doctors and nurse in the NHS issuing over a billion prescriptions for medicines each year.Ìý

And the general public are sending even fewer cards too.

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Inside Health's Margaret McCartney is on the line from our Glasgow studio, and we are joined by Mick Foy, who's pharmacovigilance manager at the MHRA. Mick, what can you ascertain from so few reports and could drug issues slipping be through the net?

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Foy

Under-reporting is a feature of all of these spontaneous schemes around the world and it's been proven that even small numbers of reports can highlight very important issues that are happening.Ìý For example, the felopidine and grapefruit juice interaction only two yellow cards came in from GPs but we were able to pick up that interaction and put new warnings in the patient information.

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Porter

Margaret, you're a GP like me, when was the last time that you sent in a yellow card?

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McCartney

Well Mark it has to be said that I am a bit of a whinger and a complainer so I probably send-off far more than the average and probably my last one was about three or four months ago.Ìý So I mean I do tend to put them in fairly often.

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Porter

Probably even more worrying because if you're sending in lots it suggests that there's a whole - there are GPs who aren't sending in any.

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McCartney

Well I think it's very difficult because so much of the time we are so used to prescribing so many drugs and actually picking up signal from noise - something that's a real side effect as opposed to something that isn't - can be quite difficult.Ìý The other problem that we have is that we're all living longer, we're all on much more medication than we were 20 years ago, so really should we be thinking of side effects much more often when people are maybe on five or six different combinations of drugs that maybe they weren't tested on originally?Ìý Maybe we should all be a bit a more reacting to the possibility that a side effect might be responsible for a problem.

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Porter

Mick, why do you think numbers are dropping off amongst the public - you'd have a thought that they'd relish the opportunity to report side effects?Ìý There certainly are listeners who seem to be very interested in side effects, something they contact us about a lot.

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Foy

Yeah and we'd encourage them to do that.Ìý I think there's a number of reasons why reporting fluctuates more so with members of the public, for example the influence by the media, campaigns, for example, during the flu pandemic we had a lot of reports, HPV vaccination campaign we had a lot of reports.Ìý So news generates reports and awareness.

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Porter

Margaret, does it worry you that one of the mainstays of drug safety monitoring in the UK is not looking particularly healthy?

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McCartney

I suppose it does and I suppose the other thing that worries me is the fact that we have more than one disease process going on and we haven't really studied very well the impact of taking lots and lots of different medications all at once in people who are a bit older.Ìý So there is that.Ìý The other problem that I have in with the MHRA is that I diligently send off data and I don't often hear anything back at all and I think that makes it problematic for me as a GP to know was that the only report on that particular side effect that they've heard off, should I be doing something else or something different - it's the kind of feedback.Ìý And we have so much stuff online now in terms of feedback from just about everything and it just feels that we don't get a huge amount of feedback back from the MHRA.

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Porter

Mick, do you routinely feedback to professionals and indeed the public, I mean if I'm a member of the public sends in a side effect do I ever get to hear what happened to that?

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Foy

You do, you get an acknowledgement from us and any further information that you request we will aim to provide you.Ìý But there's some really important and useful information resources on the MHRA website.Ìý For example we have what we call drug analysis prints where you can see every side effect that's been reported by drug substance and that is often an indication of where the side effects lie with certain products.Ìý We also provide to healthcare professionals and is available online for anyone a monthly bulletin called Drug Safety Update which identifies all of the new important issues that we've identified from these reports and other data sources that we have access to.

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Porter

Yeah and I get that and it's very good Mick but I suppose the concern is that because the numbers are relatively small that you're actually missing things that you should be telling us about.

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Foy

Yes that's a concern, we need - this is why we need more reports coming in, not just because we're worried about missing things, we think our network is good and our signal detection activities are good and we do identify new issues quite - very often.Ìý But the importance of reporting is to find out earlier, so we can detect these problems earlier with the few reports.Ìý So we're very keen to get adverse drug reactions on new drugs and the more serious drugs and particularly those that are not already listed in the patient information.

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Porter

So the take home message for anybody listening now who wants to report a side effect, first of all let's be clear, you're interested in side effects that aren't already listed in the literature, so if it's a common side effect that's already on the literature do you want to hear from the public?

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Foy

Whatever - if in doubt report, there should be no barrier to you reporting, there are no rules as such, if you suspect that the drug you've taken has caused an adverse reaction send the yellow card to us.Ìý But consider - is it important, is it new, is it in the information and that may be an indication that it is something that really, really should be reported.

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Porter

But you particularly want to hear about new drugs and about new side effects?

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Foy

Absolutely.

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Porter

Mick Foy and Margaret McCartney, thank you both very much. And you will find a link to the section of the MHRA site explaining how to send a Yellow Card on our page at bbc.co.uk/radio4.

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The discovery of Richard the III's body under a car park in Leicester has attracted more than its fair share of the headlines this week, but it was the technology used to work out how he died that caught our eye at Inside Health.Ìý

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A team at nearby Leicester Royal Infirmary used a top-to-toe CT scan to examine Richard III's remains, and is pioneering this high tech approach as an alternative to the scalpels and dissection more commonly used in conventional post-mortems.

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A move backed by the conclusion of new report from the Post Mortem, Forensic and Disaster Imaging Group recommending that we follow countries like Australia and Japan, and make much wider use of virtual autopsies to determine the cause of death in people who have died from disease, accident, or foul play.

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Professor Guy Rutty chaired the group responsible for that report, and is head of the University of Leicester's Forensic Pathology Unit.

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Rutty

What you're looking at at the moment is a post mortem scan and I'm looking currently at the outer surface of the body but with a simple click of the mouse I can dissect through virtually the muscle layers of the body through to the skeleton, through to the organs and look at the pathology that is present in a matter of seconds.

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Porter

You're obviously used to it but to me that is - well it's mind blowing.Ìý I mean you've literally gone from a picture of this chap, we're looking at head and neck here, and you've gone straight down - now we're looking at his skeleton.

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Rutty

Yes.

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Porter

And all the stages in between?

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Rutty

Both internally and externally yes.Ìý

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Porter

Do you ever use it instead of what we would regard as a conventional post mortem or is it always used as a tool alongside?

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Rutty

Undoubtedly in the future the vast majority of current autopsies, both natural and unnatural, will be replaced by this system.Ìý I have no doubt about saying that at all.Ìý What we don't have currently is the volume of evidence base to fully support that.Ìý But the way that we are moving forward now and is proposed within the United Kingdom is this will be the principle form of investigation not the autopsy.

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Porter

So you envisage a day in the not too distant future where this will become the norm, we'll be using CT scanners instead of real autopsies for most post mortems?

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Rutty

Yes.Ìý I'm undertaking procedures every day of my life that no longer need to be undertaken, which is the dissection and autopsy examination of the dead.Ìý We can do it using these systems.Ìý So the primary reason is related to the relatives and the population of the UK and to the religious groups who are opposed to these procedures, we don't need to do autopsies yet we continue to do them.Ìý So if there was an alternative to chemotherapy for a tumour you wouldn't give somebody chemotherapy and there is an alternative to an autopsy so why are we autopsying someone?Ìý And that's the question that we need to get through to people at the moment.

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Campbell

My name's Shauna Campbell, I'm a consultant radiologist and we're in Leicester Royal Infirmary.Ìý Conventional post mortem is distasteful to a lot of people and in some religions is completely frowned upon, we've got a large local Muslim population who we've been liaising with over the years and they want the body released as quickly as possible for a body over 24 hours and they don't like open post mortems, they want the body interfered with as little as possible.Ìý The same with our local Jewish population but are smaller in numbers.Ìý We're standing here just in the back of one of our two CT scanners which we use for scanning of the diseased.Ìý As you can see we're a fairly busy department, we spend most of our time scanning living patients and we're just up the corridor from the accident and emergency department, so always a bit of a hub bub.

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Porter

And presumably the living take priority over the dead.

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Campbell

The living always takes priority yes.

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Porter

What's the difference between scanning somebody who's alive and someone who's dead from your point of view?

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Campbell

Well the interesting thing is actually the whole sort of psychological aspect actually from our point of view because we're used to talking to patients and reassuring them and in terms of the technique we want to keep the radiation dose for the living patients as low as possible, so we have to be fast and we have to take corners of the physics but when we've got a deceased patient all those things go out the window and so suddenly it's odd because it's very, very quiet and of course we can eradiate to our heart's content because we're not worried about the radiation which means that we get a much higher and detailed picture.

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Porter

One of the great skills of the radiologist is knowing - looking at complicated images and knowing what's normal and what's not normal and that's difficult enough with the living but when the body's been decomposing how do you know - what's just normal decomposition and what's disease?

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Campbell

That's a really good question and it's actually really difficult and decomposition starts quite quickly, so you find gas in places where we don't normally find gas.Ìý The decomposition depends on where the body's been stored, the temperature, pre-death disease process is all sorts of things, so it's actually - as a group we've had to just build up our own knowledge just from the experience, just from looking at lots of them and learning from the pathologists as to what is normal for death and what's abnormal because of course that's important in terms of cause of death.

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Porter

The other thing is that if you're looking at somebody who's maybe 80 years old you're going to find a number of different things wrong.

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Campbell

Absolutely.Ìý Most people over 60 have calcification in their major arteries for example...

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Porter

Hardening, yeah.

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Campbell

That doesn't mean that the patient's died of a heart attack and that's been one of the major issues with this technique because of course heart attacks is one of the major cause of death, so trying to work out whether somebody's died of a heart attack or not is actually quite tricky.Ìý And we can't afford to go just on finding another disease process, we may find something else but to be sure, particularly for coroner's cases and also for the family actually because families want to know what their loved ones died of and that may be important in terms of counselling surviving family members, so it's important that we're sure - we don't just kind of jump to conclusions.

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Rutty

There will always be those cases where autopsies are required.Ìý Information to the relatives is always that if we couldn't see something they would always go on to have a conventional autopsy.

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Porter

In your experience since you've been using this technology has there ever been a situation where you've thought if I was doing a conventional post mortem I might not have found this or seen it?

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Rutty

Yes is the answer, mainly in the trauma, so we CT scan here virtually all of the road traffic collision deaths, which we examine all of them in our unit and you see pathology that is present within that that you would not normally see at a conventional autopsy because of the location or size of injuries and that's really important for not only what happened to the person but if you're thinking of certain injuries that occur at certain speeds and whether you want to redesign vehicles or you want to support the reduction of speed limits to 20 miles an hour then all of that data becomes available through the work that we're doing.

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Porter

Professor Guy Rutty, and you will find more information on virtual autopsy, and proposals to introduce the technique nationally, on our website - bbc.co.uk/radio 4 and click on I for Inside Health.

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And please do get in touch if there is a health issue that is confusing you, and that you would like us to look into - you can e-mail me via insidehealth@bbc.co.ukÌý Which is what this listener did - she has asked to remain anonymous:

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Listener

I would like to know if there is such a thing as chemo-brain? Lots of people who have had treatment for cancer talk about it, but doctors seem less convinced.

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Porter

So does it exist? A question I put to Cancer Research UK's chief clinician, Professor Peter Johnson.

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Johnson

I think everybody who treats patients with chemotherapy recognises that it does some interesting things to our ability to think straight and to concentrate and it's a direct chemical effect, I'm sure, of some chemotherapy drugs and the stronger the doses are the more noticeable the effect is.Ìý So the sorts of treatments that we often give as outpatients where patients don't come to the hospital in between treatments we don't hear very much about it because they're at home dealing with it.Ìý But I do stem cell transplants, for example, which involve very intensive chemotherapy and it's absolutely noticeable people who come into hospital with stacks of books because they know they're going to be in hospital for some time and they're planning to read them all before the chemotherapy starts and during the first few days they're able to read pages a day but the number of pages they get through goes down and down until eventually when the chemotherapy has really all gone into the system they suddenly find that they can just about manage two lines of the newspaper and then they've had enough.Ìý So there's a very noticeable direct effect on the brain of chemotherapy and I think it's a reduction in attention span and a reduction in concentration ability which is very remarkable.

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Patient

I had breast cancer last year and the thing that struck me the most following the chemotherapy that I had is that although there was all the difficulties at the time I have been left with an on-going issue, which I call chemo-brain.Ìý I can forget what I'm saying right in the middle of a sentence, that's not something that I normally do, I'm normally fairly articulate.Ìý So much so that sometimes I have people around me filling the sentences in for me because they know what I'm saying when I've completely forgotten.Ìý And things that I would normally have found really easy and wouldn't have thought would be a problem I'm now being affected by, so one example would be when I go shopping I completely forget half of what I'm supposed to buy if I don't make a shopping list whereas previously I'd never need to make a shopping list because I'd just have the routine of going round the shop and I'd know what I had to buy for the kids because I'd done for so long.

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McCarthy

My name's Ros McCarthy, I'm a clinical neuropsychologist here at Southampton University Hospital.Ìý Patients with these problems complain of difficulties with attention, difficulties with memory and concentration.Ìý There's so many different drugs being used in chemotherapy it's quite difficult to disentangle what's going on that might be due to the chemotherapy from what might else be going on in terms of their - the stress that they've experienced as a result of being diagnosed with cancer and being treated for it and also any hormonal changes that may be happening as a result of the chemotherapy or of any operation that they've undergone.

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Porter

Is there any evidence looking at other people who might go through that sort of degree of stress and ill health but without the chemotherapy that they get similar changes?

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McCarthy

People who are under a lot of stress will often exhibit difficulties with memory and concentration, people with serious back pain can have marked cognitive difficulties.Ìý In all of these cases although there's suggestive evidence that there's something going on at their neurological level we are - nothing that's convincing has been sorted out yet.

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Porter

Has much research been done into this area?

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McCarthy

Not a lot I'm afraid.Ìý I think it's an area that really does cry out for proper research to be carried out so that we can actually disentangle all the various contributing factors.

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Patient

The other thing that I find that I'm doing is with the children in a very domestic way that I forget what their schedules are and what they're doing and they tell me important things about their schedules or even important things about their lives and I would never have not known something that's important to them and I've just found that I've forgotten and it's very difficult because it's hard to explain to them that it's not me, it's my brain because you don't really want to say to them.Ìý If my daughter says she's going out somewhere or even she's achieved a certificate - she got a certificate this week through the post and I couldn't - my husband told me about it and I wanted to say well done to my daughter but by the time I got to my daughter I couldn't even remember what she'd achieved it for, I knew it was maths but no more than that.Ìý And I think they can get hurt.

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McCarthy

One of the things that people get worried about, particularly people who are in their middle years, is this the first sign of Alzheimer's Disease and that's the kind of reason that people would come to see me but in fact it's probably a side effect of chemotherapy that they're not concentrating very well and hopefully things will settle down to some extent.Ìý It's very variable as to how much things settle down but it's unlikely to be getting worse.

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Porter

What sort of timescale are we talking - is it a matter of days or weeks...?

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McCarthy

No, no we're talking probably months or years.

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Porter

Ros McCarthy.

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Our report suggesting that close to three quarters of the adult population in the UK lacked the necessary literacy and numeracy skills to properly understand body mass index charts prompted a number of you to get in touch including Angus Smith.

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Smith

My experience was farcical.Ìý The health nurse weighed me at about three or four kilograms over what I knew I weighed.Ìý As a breeder of pedigree cattle I weigh all newborn calves by carrying them as I stand on scales and then deducting my weight.Ìý My scales are peer reviewed.Ìý I was then measured for height - at five centimetres shorter than the last time I'd checked.Ìý As she never moved from her chair I had to relay the reading to her.Ìý A check at home revealed I had only shrunk by five millimetres.Ìý Next time I visited the surgery I mentioned this to the doctor who said she had seen the handyman come into her surgery, tap the wall until he found a joist and fixed the height slide without doing any measuring.Ìý I hope no data from this health centre ever gets used to test the hypothesis.

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Porter

Thank you Angus.Ìý And, for a problem that is supposed to be pretty rare, our report of transient global amnesia - that's temporary loss of memory - continues to strike a chord with at least 10 of you so far describing episodes that have lasted anywhere from 15 minutes to 12 hours.Ìý Everywhere from on stage at a folk festival - that must have been embarrassing - to ski slopes in Switzerland.Ìý One common theme though - you all made a full recovery and no abnormality could be found.Ìý Strange indeed.

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Last week's report on the use of genetic mapping to help develop targeted cancer therapies prompted questions about the implications of having relatives with cancer - does it mean you are more likely get cancer too?

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Professor Nazneen Rahman is Head of Genetics and Epidemiology at The Institute of Cancer Research and the Cancer Genetics Unit at the Royal Marsden.

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Rahman

People do worry about having a family history of cancer which is not surprising because cancer's a very common condition - about one in three people will get cancer.Ìý And we use the term cancer to actually cover a lot of different types of conditions.Ìý So because it's common we expect to have relatives who have cancer and in itself that's not overly worrying, particularly if there's lots of different types of cancers in the family.

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Porter

This is the - patients often come in and talk about cancer don't they as if it is one condition.

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Rahman

Yes I suppose a comparison would be infections, we can use the word infection to cover lots and lots of different things and those aren't usually linked and aren't linked to the infections that have happened in our relatives.

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Porter

So just because you've got a family history of people who've had a variety of different cancers doesn't mean there's any connection between those at all.

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Rahman

No that's right.Ìý There are lots of different factors that can cause cancer, it's a complicated condition.Ìý Genetics and hereditary factors can sometimes be involved but usually they're not the primary reason why a person has got cancer.

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Porter

So let's look at when a family history does become worrying.Ìý What sort of characteristics in a story would concern you as a clinician?

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Rahman

Well if there are lots of cases of the same cancer in a family, that can be concerning, particularly if it's a rarer cancer.Ìý If it's something like breast cancer which affects about one in eight women then it's not unusual to have a few cases of breast cancer in a family and generally we don't find that that's due to a particular potent genetic factor running through the family.Ìý But if there are lots of cases of breast cancer - five, six - or if sometimes we know some cancers do go together, so breast and ovarian cancer, we know can sometimes be linked due to faulty genes then that could be a concern.

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Porter

What about the age at which someone develops the cancer?

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Rahman

That can be a signal that there may be something that's increasing the risk of cancer in a family, such as a genetic factor.Ìý So if the cancer has occurred at a younger age than is typical for that cancer, so for example for something like breast cancer which usually occurs in the 60s or older if we're seeing a case in somebody who's in their 30s that's more likely to be genetic but it doesn't mean it definitely will be.

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Porter

If you had a suspicious story from somebody - I mean say somebody's got two relatives, close relatives, who developed breast cancer before the age of 50, another one who had cancer of the ovary and you're starting to think oh I wonder if there is something going on here, I mean what steps can we take to find out if there is?

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Rahman

It really helps if we can find out whether those cancers have been due to a gene mutation.Ìý Often we see the relative and they're worried but we don't yet know whether a faulty gene or gene mutation has caused the cancers.Ìý So what we really need to do is if we find people who've actually got cancer, try and work out at that stage whether those cancers have been due to gene mutations, if they have then we've got really good information that we can then pass down through to the relatives and they may or may not be at increased risk of cancer depending on whether or not they've inherited that gene mutation.

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Porter

I suppose the other big thing is that if you do identify an increased risk what can we do about it?

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Rahman

So it will depend - currently there are about a hundred genes and a hundred conditions that we know can be associated with an increased risk of cancer, most of those are very rare but there is a lot of information that can be helpful.Ìý The first is if we find in a family that there is a genetic cause then we can test people to see whether they've inherited it and the ones who haven't we know that despite that family history they're not actually at increased risk and neither are any of their family, so that's really reassuring news that's really helpful.

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Porter

And what about those who are at increased risk?Ìý Let's use the example of the breast gene.

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Rahman

So if you're a well person, a woman and you're found to have a mutation in one of the breast cancer genes that means that you will be at increased risk of breast cancer and at increased risk of ovarian cancer but we know that information before that person's got cancer so they potentially can have screening and preventative measures to reduce that risk.

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Porter

So obviously even though we can identify the mutation, perhaps work out what's gone wrong, we can't do anything about that mutation, it's about looking after the individual who's carrying that, so it might be increased monitoring at one of the end of the spectrum, right through to removing the part that's turns cancerous - I'm thinking mastectomy, removing of the breast in people with breast cancer?

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Rahman

Yes currently we don't have a way of correcting that gene if it's wrong, it's present in every cell, it's been there right from the very beginning, so we haven't got a way currently of changing that.Ìý But yes we can do potentially increased screening and the preventative options, particularly say for example, for the ovarian cancer, keyhole surgery to remove the ovaries after one's completed one's family is generally very well tolerated and good preventative measure.

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Porter

I suppose - I mean the upside of people worrying about their family history is it does drive them in to see us doctors to ask for guidance and in some cases there will be a problem there.

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Rahman

Yes that is true but I think often when that happens we don't have the information available to actually help them because the key information that's most helpful is whether or not there was a gene mutation that had caused their relative's cancer.Ìý So often when the relative comes to see us that's the first time anyone has thought about whether there might be a genetic mutation that's caused the relative's cancer and what we'd really like to do is try to make it much more routine that if there is a genetic cause of a person's cancer that that's found out for that person with cancer.Ìý Not only because it helps the relatives but because it is important for that person with cancer because they might be at increased risk of other cancers and it may affect their treatment.

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Porter

So we become more proactive effectively.Ìý And presumably when you're mapping out cancers you'll be able to tell whether there's a genetic element to them will you?

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Rahman

Yes increasingly that's easy because the technology's changed that makes this kind of genetic mapping and testing easier, faster and much less expensive.Ìý So we have a programme at the moment that's called the Mainstreaming Cancer Genetics Programme where we're trying to make that type of genetic testing much more routine and undertaken when people are actually diagnosed with their cancers.

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Porter

So the first case could come in of a woman with breast cancer you can say this is actually something that might have implications for your sister, rather than waiting for the sister or the aunt to come in later and go I'm a bit worried I've had two or three people in my family affected?

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Rahman

Well absolutely, there's the issue about whether it has implications for their families but also for that person with cancer if their cancer has been due to a gene mutation that may means that they're at increased risk, for example, if a woman's got breast cancer and it's due to a BRCA mutation that means that they're at increased risk of ovarian cancer and we've got that information ahead of time and so we can potentially reduce that risk.

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Porter

Professor Nazneen Rahman.

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Next week we'll be looking at first aid and asking why we Brits are so poorly prepared to help our near and dear if they collapse or have an accident.Ìý And contraception and the older woman - can you really take the pill up until the menopause?Ìý Join me next week to find out.

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ENDS