GHA Public Health

Osteoporosis is a condition that weakens bones, making them fragile and more prone to breaking. The condition is often diagnosed when a fall or impact causes a bone to break, with the most common injuries occurring in the wrist, hip and vertebrae. Osteoporosis is called a “silent disease” as patients do not notice any changes until a bone breaks, as the bones often lose density over a number of years. Once the bones have become weakened some of the symptoms which my present include:

• A gradual loss of height 
• Stooped posture (particularly in older patients)
• Increased bone fractures
• Back pain as a result of fractured vertebrae. 

Sometimes even the action of coughing or sneezing can cause a broken rib or partial collapse of vertebrae in people suffering from osteoporosis.

Causes of osteoporosis

Loss of bone is a natural part of the ageing process. Women are also more likely to lose bone after the menopause. This increases the risk of osteoporosis, particularly if menopause has started before the age of 45 or they have had an oophorectomy (ovaries removed). 

Other factors can also increase the risk of osteoporosis onset, including:

• Family history of osteoporosis 
• Had extended bed rest
• Having a low body mass index (BMI)
• Lack of physical activity 
• Heavy smoking 
• Significant alcohol consumption 
• Having or having had an eating disorder 
• Taking high doses of steroid tablets for prolonged periods 
• Medical conditions such as inflammatory conditions, hormone related conditions, or malabsorption. 
• Long-term use of medications that affect hormone levels, such as anti-oestrogen tablets that women may take after breast cancer. 

Osteopenia 

Osteopenia is the stage before osteoporosis and occurs when bone density is below average. Osteopenia does not always lead to osteoporosis and there are steps you can take to reduce your risk from developing the condition. There are bone-strengthening treatments your doctor may prescribe, depending on the severity of your condition. 

Preventing osteoporosis 

If you are at risk of developing osteoporosis, there are steps you can take to help reduce your risk and keep your bones healthy. This includes: 

• Keeping physically active to help keep your bones as strong as possible. Healthy adults should aim for 150 minutes of moderate intensity exercise a week or 75 minutes of vigorous intensity exercise. Try to incorporate strengthening activities on at least 2 days a week. Regular weight-bearing exercise, such as light weight training, walking, climbing stairs or hiking are important. 

• Aim to eat a balanced diet including foods which are rich in calcium and vitamin D. 
• Taking a daily supplement containing 10 micrograms of vitamin D. 
• If you are a smoker, consider stopping or cutting down. Appointments with the GHA free ‘Stop Smoking’ service are available on 20052441. 
• Reduce alcohol consumption. 

living with osteoporosis 

Osteoporosis does not usually cause discomfort until a breakage occurs. However, breaks, in the spine can be a source of chronic pain. If you have suffered from a fracture there are some things which can help you in your recovery. Hot and cold treatments such as warm baths and cold packs can be used to reduce discomfort. Additionally, transcutaneous electrical nerve stimulation (TENS) can be used to stimulate the nerves and reduce pain. If your condition is affecting your day-to-day life, or you have concerns about coping with a long-term condition, speak to your healthcare provider. 

If you are diagnosed with osteoporosis, it is important to try and reduce the risk of falls. Remove hazards from around your home and ensure you have regular sight and hearing tests. 

Breast cancer is the most common type of cancer in women. In Spain, nearly 30% of cancers diagnosed originate in the breast. Although its incidence has grown in recent years, advances in treatment and early diagnosis of the disease deliver an increasingly improved prognosis. 

Tomas Arrazola, a pharmacist specialising in oncological pharmacy at HC Marbella and HC Ceuta, talks about the new drugs currently being given to treat this disease.

How have breast cancer drugs evolved? 

Fortunately, in recent years knowledge of the molecular biology of tumours has increased, allowing the development of treatments which improve on the results from classic chemotherapy. They are basically of two types, the first are treatments which target specific mutations and the second are immunotherapy drugs which bolster our immune system so it recognises and attacks the tumour.

What new drugs are there?

Before we discuss new drugs for breast cancer, we need to have some understanding of the 3 breast cancer subtypes: luminal, HER2 and triple negative. The novel approaches to treatment are based on this information. 

Luminal: this subtype of breast cancer is highly hormone dependent and is treated with drugs which block the action of these hormones. Cell cycle inhibitors such as Ribociclib, Palbociclib and Abemaciclib used in advanced disease are no longer new drugs, and there is growing evidence that they may be useful neoadjuvant and adjuvant treatments in localised disease. When these drugs are used in advanced disease, at some point they lose their effect; 50% of the time this loss of effect is due to a PIK3CA mutation for which we have a drug called Alpelisib. This drug is not yet available commercially, but we have treated 5 patients with it in our centre with encouraging results.

HER2: This subtype is characterised by its HER2 receptor amplification and is the most aggressive, however, the arrival of Trastuzumab in early 2000 resulted in a radical change in both the treatment and prognosis of the disease. Trastuzumab results have been improved further by the introduction of Pertuzumab, in combination with Trastuzumab, in both advanced and localised disease. Subsequently antibody-drug conjugates arrived, these combine a monoclonal antibody with a cytotoxic drug with the aim of targeting the cytotoxic drug at the cell that has the HER2-amplified receptor, thus destroying it. Unlike when receiving conventional chemotherapy, other healthy cells are largely prevented from being affected. These antibody-drug conjugates use Trastuzumab as a shuttle, they are Trastuzumab-Emtansine and Trastuzumab-Deruxtecan, the latter has delivered results never seen before in the heavily pre-treated patients treated in our centre. Trastuzumab-Deruxtecan has recently delivered impressive data even in those  patients who have breast cancer with weak HER2 expression.

Triple negative: the name as such lacks definition, it has no hormone receptors for oestrogen or progestogen, or amplification of the HER2 receptor, it is the most aggressive form and there are fewer drug treatments available. Fortunately, there is a ray of hope as these are highly immunogenic tumours in which immunotherapy drugs can play a key role. Both Atezolizumab and now Pembrolizumab have been approved by regulatory agencies for their use in advanced disease; data also exists on localised disease, with Pembrolizumab indicated as neoadjuvant treatment and as adjuvant treatment afterwards.

Within this subtype, not an insignificant percentage of patients have a BRCA gene mutation which contributes to an error in DNA repair. These patients are candidates for treatment with Olaparib or Talazoparib in advanced disease, or even Olaparib as adjuvant treatment in the case of localised disease. 

Triple-negative conjugated antibodies such as Sacituzumab-Govitecan are also now available, already approved in the USA, they will be available in Europe in the near future.

At HC, we are committed to innovative treatment and to providing the latest alternative drug treatments for our patients, even if they are not yet generally available. We are increasing the range of new emerging treatments through involvement in new clinical drug trials. 

Breast Cancer Screening

October marks breast cancer awareness month, and awareness of breast cancer is crucial to early detection and better health outcomes. In some cases it will be possible to notice visible changes to the breast, check out the ‘Know Your Lemons’ website and app for more details. However breast screening is the best tool we currently have to help detect cancers before there are signs of disease, when for example they are too small to feel.

In Gibraltar, women between the ages 40 and 70 are invited for screening mammograms at 2-yearly intervals.

Trans men, trans women and anyone non-binary (between 40 – 70 years) may be invited automatically or may need to talk to the local breast screening team.

Anyone can get breast cancer. 

This includes women, men, trans and non-binary people.

•
The chance of getting breast cancer increases as you get older. 

•
Most breast cancers are diagnosed in women over 50 years old.

It is important for all those who are eligible to take advantage of the screening program. Invitations are sent in the form of a slip which must be returned to the screening nurses in order to obtain an appointment.

You can have breast screening whatever size or shape your breasts are. Those with implants can also be screened safely; there are several methods mammographers (specialists who help take the breast x-rays) use.

Breast screening cannot stop someone getting breast cancer, but it is the best way to spot cancers at an early stage.

Finding cancers early can make it:

•
more likely that treatment will be successful

•
less likely you’ll need to have any surgery

• more likely you’ll be cured

If you are eligible for screening and have not been contacted, or wish to make an appointment or just find out more, contact:

GHA Breast Screening Team

Call : 200 72266 Ext.2214 

Email: BreastScreening@gha.gi

Breastfeeding Week is an annual event organised by the World Alliance for Breastfeeding Action (WABA), a global network that works alongside the World Health Organization and UNICEF to protect, promote and support breastfeeding around the world. The event raises awareness of the health and wellbeing outcomes of breastfeeding and the importance of supporting mothers to breastfeed for as long as they wish. 

Whilst support at the individual level is crucial, WABA emphasizes that breastfeeding is a public health issue that requires investment at all levels. The opportunity to create a warm chain of support for breastfeeding that includes health systems, workplaces and communities at all levels of society is vital.  

Breast milk is tailor-made for your baby, has all of the easily digested nutrients in the right proportions, and contains antibodies and properties that prevent and protect against infections. Whilst any amount of breastfeeding is beneficial, exclusively breastfeeding your baby for 6 months offers a lot more protection. 

Breast milk has many benefits for both baby and mum.

Baby:

• provides protection from infection – breast milk provides natural antibodies that help your baby fight infections like tummy bugs, diarrhoea, colds; and chest and ear infections

• is rich in vitamins and nutrition – your breast milk provides the perfect combination of vitamins and nutrition, it is also much easier to digest than first infant formula

• protects long-term health – breastfed babies are less likely to develop diabetes, or become overweight when they are older

• reduces the risk of sudden infant death syndrome (SIDS) and childhood leukaemia 

Mum:

• helps your uterus get back down to size 

• promotes bonding with baby 

• protects your health by lowering your risk of breast cancer, ovarian cancer, osteoporosis (weak bones), diabetes and cardiovascular disease (conditions affecting the heart or blood vessels).

Your diet whilst breastfeeding

You do not need a special diet while you are breastfeeding; just try to include a well-balanced, healthy variety of fruits, vegetables, starchy foods, dairy products and protein. For tips and advice, visit: https://healthygibraltar.org/healthy-eating/ 

How long should I breastfeed?

The World Health Organisation recommends that babies should have only breast milk for around the first 6 months of their lives and then continue to be breastfed for 2 years and beyond.

It is particularly important to give your baby only breast milk in the early days as this can affect your milk production. If you find it difficult to only breastfeed or you do not want to, try to give as much expressed breast milk as you can; your partner can help with feeding too.

When to feed your baby

If your baby is hungry or thirsty, they will show signs of hunger by:

• moving

• putting their hand to their mouth

• rooting

• becoming agitated or upset  (try calming them by cuddling, giving skin-to-skin contact, talking and stroking)

Keeping your baby close will help you recognise these signals. Responding to their needs will not spoil them, but will help them feel safe and secure.

Understanding first feeds

Your baby’s tummy is the size of a cherry on the first day; during the first 24 hours after the birth, babies usually wake and feed often to get your milk supply started. This may seem like a lot of feeding but is normal and will settle down.

Your baby’s tummy will grow from the size of a cherry on the first day to the size of an egg by the end of the first month. They will need to feed frequently (8 to 12 times in a 24-hour period) as small amounts of milk at each feed will fill them up.

As baby’s tummy grows, they will start to take a bit more at each feed. Feeding them as often as they want will help your body prepare a good supply of milk for the days, weeks and months ahead.

As your baby feeds more and grows, the gaps between some of the feeds will get longer. Responding to your baby’s feeding cues will ensure they feed frequently. 

Note:
It is not possible to overfeed a breastfed baby.

Dads and partners

Emotional support and encouragement from dads and partners are as important as practical help. Dads and partners play a key role and can help mum by:

• taking an interest and finding out about breastfeeding, so you can give help and suggestions if your partner is struggling

• understanding it takes time and practice for mum and baby to get the technique right while feeding 

• looking after mum while she’s breastfeeding and making sure she is comfortable

Getting support to breastfeed

Your midwife, health visitor or family nurse can provide information and help, and show you:

• how to hold your baby

• how to help them take your nipple and breast in the right 

It is also helpful to chat to a friend who successfully breastfed her baby or contact the local breastfeeding association:

https://www.facebook.com/Gibraltarbreastfeeding/