It’s unclear what is behind the increase in new cases but factors including rising levels of obesity and the trend to having fewer children, later in life (early pregnancy is protective). The fall in the death rate, however, is much easier to explain and due to a combination of the impact of screening, the introduction of specialist breast cancer care services as well as better treatments. And new developments for prevention currently being mooted could soon reduce the toll further.

Despite being able to identify women most at risk of developing breast cancer we have not been able to offer them much up until now, other than close monitoring in the hope that we catch any tumours early, or, in extreme cases, surgical removal of their breasts (mastectomy). But new research currently being considered by advisory groups both here and in America, could see high-risk women being offered daily medication to protect them.

So who is likely to be offered the drugs? How do they work? And, what are the downsides? UK plans are currently under review by the National Institute for Health and Care Excellence (NICE) and due to be announced next month, but the US authorities have already suggested a tentative threshold for offering preventative treatment of a 3% or more risk of developing the condition over a 5-year period – risk is worked out using the National Cancer Institute online tool at www.cancer.gov/bcrisktool .

Access to the calculator is open to the public and results based on the answers to seven questions on subjects ranging from past breast problems, to family history of the disease and whether or not you have had any children, and at what age.

The drugs – tamoxifen, raloxifene and others – work by blocking oestrogen receptors on cancer cells (oestrogen stimulates breast cancer growth and spread in around 8 out of 10 tumours). Think of them as having the opposite effect to fertiliser on a plant, they impede, rather than nurture growth and spread.

Last week a landmark study in The Lancet, which followed 80,000 women over ten years, found that 42 high-risk women would need to take the drugs for five years to prevent one new case of breast cancer – benefit that has to be offset against potential hazards such an increase in blood clots and cancer of the womb (see below).

Whatever NICE’s final decision, medication will only ever be part of a larger preventive strategy that will always include self-help measures. We may not be able to choose our parents and determine our genes, but we can influence other important risk factors. Being overweight, drinking alcohol, a sedentary lifestyle, a poor diet, taking the Pill or HRT, and leaving it late before starting a family all increase the risk slightly, and are potentially within a woman’s control.

I am not suggesting that women have children in their twenties, or become teetotal just to reduce their cancer risk, but those who are worried should be informed that these are influential factors – albeit small ones in the grand scheme. The link with obesity is more important in my view, and one that few women seem aware of despite Cancer Research UK estimating that obesity now accounts for as many as 1 in 10 cases of breast cancer.

And, last but not least, there is vigilance. Make the most of the National Breast Cancer Screening Programme if you are 50 or over, and report any worrying changes in your breasts promptly whatever your age. The earlier the disease is caught, the better the outcome.

 For more information on breast cancer, its treatment and plans to introduce preventative medication visit www.canceresearchuk.org

 As always the use of preventative medication is about balancing benefit against risk. Current research suggests that for every 1,000 otherwise healthy women deemed to be at high risk of developing breast cancer, and taking tamoxifen for at least 5 years: 

• There would be 21 fewer breast cancers diagnosed over a decade

• But there would be 6 additional blood clots (DVTs)

• And up to 4 additional cases of cancer of the womb

As many as half a million people in the UK with stomach problems previously attributed to irritable bowel syndrome (IBS), could actually have another cause for their symptoms that is likely to be much easier to treat. Ideopathic bile acid diarrhoea (BAD) has really only appeared on the medical radar within the last decade, but there is now a growing understanding that it accounts for a significant proportion of the five million of so people troubled by IBS at some stage of their lives.

A typical person will secrete as much as 8 litres of digestive juices a day, including 500-1000mls of bile, nearly all of which is reabsorbed in the latter part of the bowel. In the case of bile, around 95% is recycled this way, but if the reabsorption process is hampered then irritant bile reaches the colon where it speeds up transit time causing diarrhoea.

Tell-tale signs suggestive of BAD include unusually coloured motions (they vary in colour but often contain greens or yellows), loose stools that float and are difficult to flush away, and needing the loo during the night. All of which may be worse after a particularly fatty meal (bile secretion varies depending on the amount of fat in the diet).

Although there are a number of recognised conditions – ranging from Crohn’s disease to a side effect of gall bladder removal or radiotherapy treatment for cancer – that can interfere with bile acid recycling, patients with these generally don’t end up with a label of IBS because there is an identifiable cause. However, in idiopathic bile acid diarrhoea (the type likely to be confused with IBS) there is no such demonstrable trigger and the problem is thought to be due to a genetic glitch in the transport system responsible for collecting the bile salts from the bowel and recycling them.

There is a special test to confirm the diagnosis but it not widely used as it is very expensive (as much as £600 per patient) and awaiting approval by the National Institute for Health and Clinical Excellence (NICE). A simpler way to pick up the problem is to offer patients a trial of therapy – prescribing a drug that mops up the excess bile salts to see if symptoms improve (something that typically happens within a few days).

The cheapest option is a granular product called colestyramine (Questran), which is mixed with at least 150mls of water or other liquids and taken three times a day. It sounds simple, but it has the consistency of wallpaper paste and a lot of people struggle to swallow it. There is a pill-form (Cholestagel) but while a month’s supply of colestyramine costs just over a tenner, the tablets costs nearly £100 so doctors are naturally reluctant to prescribe them. If the drugs work they need to be continued indefinitely to maintain any benefits.

A low-fat diet may also improve symptoms, and making breakfast and lunch the main meals of the day, and only snacking in the evening may reduce the need to get up during the night.

If any of this rings a bell with you then your first step should be to discuss your symptoms with your GP. He or she can initiate a trial of colestyramine and if it works well then it probably clinches the diagnosis. If the response is less clear cut then referral to a gastroenterologist may be warranted as they are the only ones who have access to the confirmatory test.

And even if your IBS symptoms don’t fit with BAD, you should take some consolation from the fact that doctors are beginning to take a fresh look at what many regard as a “dustbin diagnosis” – somewhere you put everyone that doesn’t fit into any other category.

IBS has always been a difficult condition to treat but that is not surprising given that it is not caused by one specific problem. The discovery of BAD will help a significant proportion of people with IBS and I very much doubt that it will be the last advance in our understanding of this common syndrome.

 For a definitive (if rather complicated) review of the diagnosis and treatment of BAD go to www.ncbi.nlm.nih.gov/pmc/articles/PMC3002596/

• The key features of IBS are abdominal pain or discomfort, bloating and a change in bowel habit that have gone on for at least six months and where no other cause (such as infection, colitis or diverticulitis) can be found

• In approximately a third of cases the predominant disturbance in bowel habit will be loose stools or diarrhoea (IBS-D). In another third, it will be constipation (IBS-C) and the remainder will alternative between the two

• IBS affects both sexes and can strike at any age but is most common in women in their thirties and forties

In the meantime you might want to listen to this edition of Inside Health – www.bbc.co.uk/programmes/b019dl1b – which looks at what American authorities have proposed (including how they define a woman as high risk), as well as covering common side effects of tamoxifen with a UK surgeon.

You will find the breast cancer risk tool mentioned in the interview here: www.cancer.gov/bcrisktool/

This is a controversial area because there is so much individual variation – not surprisingly, one rule can not be applied to all.  There are no gold standard trials into the hazards of regularly pushing your heart rate above this suggested maximum but there are sound physiological reasons as to why it may be protective (very high intensity work-outs increase the metabolic demands of the heart, dramatically raise blood pressure and lead to twisting movements during contraction that are thought to increase the likelihood of disruption of materials deposited in artery walls).  That said, many people, including the middle-aged and elderly, can push themselves beyond this quite safely although they tend to be fitter than average individuals.  My advice was aimed at more sedentary folk concerned that their work-outs may be doing them harm.

But, perhaps the most important point to make is that more people have strokes in their beds than they do in the gym.  Experiences like Andrew Marr’s are actually quite unusual and should never put people off exercise – the benefits of which, far outweigh the risks for most of us.

Anyway, if you have never heard of 111 – as many haven’t – here is an overview of what to expect.  And, hopefully, your experience will be better should you ever need help.

Mark

The last thing a beleaguered NHS needs is more change but that is exactly what it has had thrust up on it in the spades this month. Not content with the biggest administrative reforms in the 65 year history of the service, NHS England has decided to try and introduce a new way of accessing urgent care – NHS 111 – and all in the week after the Easter Bank Holiday. What could possibly go wrong?

According to the bumpf accompanying the launch of the new 111 number will “make it easier for the public to access healthcare services when they need medical help fast, but it is not a life threatening situation”. And it provides a one-stop-shop “that ensures people receive the right care, from the right person in the right place at the right time”. Put simply, if your GP surgery is shut, your problem isn’t urgent enough to dial 999 and you are not sure if you should go to A&E, you dial 111.

Well that’s the theory anyway. Cynical doctors and nurses have been forecasting problems ever since the scheme was announced, and time has proven them right. The launch of the service has had to be aborted in parts of the country, including Manchester, Shropshire and South London, because the new service simply couldn’t cope, or wasn’t ready.

Indeed roll out has now been postponed in half the 46 regions across England after people have been left waiting hours for answers to their queries, and ambulance services have been overwhelmed as desperate callers resort to 999.

I have tried my local 111 service on several occasions and, to be fair, my call has been answered in seconds each time, but that was during working hours when staff are likely to be at their quietest. What concerns me about the recent teething troubles is that the service has struggled despite most of the public never having heard of 111 – if those running it can’t manage with a soft launch ahead of a national awareness campaign, then the future doesn’t look bright. Scotland, Wales and Northern Ireland must be watching with interest.

NHS England says it is aware of difficulties in some areas, but measures are already in place to deal with them and that roll-out will continue across the rest of the country, but only when everyone is ready. So, assuming initial wrinkles are ironed out, what can we look forward to?

Well the new service replaces NHS Direct (0845 46 47) and will be run by different organisations in different regions– everyone from GP out-of-hours cooperatives and local hospital trusts, to ambulance services and private companies, depending on whose tender was accepted.

Your calls will be taken by trained staff (although perhaps as not as well trained as some hoped) and triaged using a computer based system to assess your needs and determine the most appropriate action. Staff can refer on to qualified nurses where required, and resulting actions may vary from dispatching a blue-light ambulance, to providing simple reassurance and advice on self-care (take two paracetamol and go to bed). And all that goes inbetween including onward referral to out-of-hours GPs or the local A&E department (staff will, in some circumstances, be able to book appointments at GP surgeries and urgent care clinics while the caller is on the phone).

The idea is that you only ever need remember three numbers. 999 for life threatening emergencies such as chest pain, someone collapsing, or a serious road traffic accident. The number of your local GP surgery for routine problems like troublesome backache, an itchy rash, a sore hip or discussing the pros and cons of HRT. And 111 for everything in-between, or for when your GP surgery is closed (in my part of the country, Gloucestershire, out-of-hours calls to surgeries are now directed straight to 111).

To find out more about how to use the NHS 111 Service and to see if it is up and running in your area, visit www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Pages/NHS-111.aspx

The NHS 111 Service is accessed by dialing 111 from any landline or mobile phone. Calls are free and the service is available 24 hours a day, 365 days a year for people:

• Who need medical help fast, but it is not a 999 type emergency

• Who don’t have a GP, or know who to call

• Who think they need to go to A&E or another NHS urgent care service

• Or, who require health information or reassurance about what to do next

People living outside areas with the new 111 service will continue to use NHS Direct on 0845 46 47 (NHS 24 in Scotland 08454 24242).

Measles is often dismissed as an insignificant childhood illness but recent experiences suggest it is anything but. Fifty-one of those affected in Swansea so far have required hospitalisation, and a similar outbreak in Dublin in 2000 suggests there could be worse to come; during the Winter and Spring of that year there were nearly 1500 cases of measles in the city. A hundred children were hospitalised, 6 of whom ended up in intensive care, and three died.

Before routine immunisation against measles was introduced in the UK via the MMR in the late eighties, there were as many as 800,000 cases in a bad year. Complications were common – 1 in 20 cases developed pneumonia, 1 in 100 had convulsions and 1 in 1000 had encephalitis (potentially fatal inflammation of the brain).

The return of measles- there has been a six-fold increase in the UK over the last decade – is a legacy of the autism scare triggered by the now discredited Dr Andrew Wakefield. Worried parents turned their backs on the vaccine during the nineties and a huge cohort of children grew up with no immunity to the disease. And we are not the only country to be affected – popular holiday destinations like France, Italy and Spain are all facing a similar resurgence.

Ideally 95% of children should have both MMR jabs to ensure that measles is controlled to such a degree that outbreaks are unlikely, but the figure in the UK is currently only 88% – the highest for 13 years, but still short of ideal. And the national average hides pockets of much lower coverage.

Uptake is best in Scotland (93%) and Northern Ireland (91%) with Wales coming in third at 89%. But in London the uptake is just 80%, and if an epidemic can start in Swansea, then imagine what might happen in London with its low vaccination rate and much bigger population.

Fortunately it is not too late to act. Anyone who has not had the MMR, or received their second booster dose, should get vaccinated. The under-25’s are the main group at risk because people over this age will have either had the MMR in the pre-Wakefield days when uptakes were good, or if older, they are likely to have good natural immunity after catching the disease in the pre-MMR era.

And measles isn’t the only threat for those who have missed out on the MMR. Mumps is actually more common than measles and while generally mild in young children it can be much more serious in adults in whom complication rates are high. One in 5 men develop inflammation of the testicles (although the infamous infertility is a very rare complication), 1 in 7 cases develop meningitis, 1 in 1,000 will develop inflammation of the brain (encephalitis), and 1 in 15,000 will lose their hearing in at least one ear.

Rubella (german measles) is less of a problem but can have catastrophic consequences in pregnancy. I must declare a vested interest here as my younger sister, Caroline, was born profoundly deaf when my mother caught rubella during the third month of her pregnancy. If you have not had the MMR and are planning on starting a family, please get immunised.

To arrange catch-up vaccination contact your practice nurse at your local surgery, or student health services if you are at college/university. And for more information on all routine immunisations visit www.nhs.uk

• Measles is one of the most contagious viruses known to man. It’s spread via droplets produced by breathing, coughing and sneezing, and cases are infectious from the start of symptoms until the 5th day of the rash.
• Early symptoms – a temperature, sore red eyes and spots along the inside of the cheek – typically develop within 10 – 14 days of contact with someone with the disease, with the characteristic skin rash developing 3 – 4 days later.
• There is no specific treatment and therapy is aimed at symptom relief (paracetamol etc). Most cases settle within 7 – 10 days.