Pink ribbon. The juxtaposition of these two words translates into arguably the most recognized symbol anywhere, the looping image firmly embedded in our collective psyche and associated with breast cancer awareness. These words also conjure up a range of thoughts, emotions and an awareness of breast cancer that has transformed this terrible disease into a cause that extends beyond medical research. It is safe to say that minus the ribbon, the color pink alone has come to symbolize breast cancer awareness.
The pink ribbon has created an awareness that has resulted in a proactive approach and attitude among the general population, especially in regard to prevention and early detection. It is estimated that the five-year mortality rate attributed to breast cancer is approximately 14 to 18 percent.1,2
Why have I mentioned breast cancer and its associated symbols in a column dedicated to diabetes?
Simply stated, we must perceive the complications associated with diabetes in the same manner as with breast cancer. It is safe to say that the majority of people, not to mention primary care providers, do not have an understanding of the magnitude of the problem. Typically, there is a lack of correlating catastrophic health events, such as heart attack, stroke and diabetic foot ulcers (DFU) to each other, not to mention disturbing mortality rates in which complications of diabetes are factors.
If we are to make any significant progress in the healing of diabetic ulcers and simultaneously reducing lower extremity amputations, heart attack and stroke, we must begin the process of linking these complications into one comprehensive issue, instead of the myriad described as “complications from diabetes.”
The SAGE Group is a research and consulting company specializing in atherosclerotic disease in the lower limbs, specifically peripheral arterial disease (PAD), critical limb ischemia (CLI) and acute limb ischemia. Its most recent research focuses on PAD and diabetic foot ulcers.
According to the SAGE Group, PAD affects 2 to 3.7 million U.S. citizens with diabetic foot ulcers.3 Additionally, 1 million patients suffer from critical limb ischemia, the most severe and deadly form of PAD.
Recent research indicates that diabetic ulcers in individuals with PAD are a different disease than ulcers caused by neuropathy alone.4 Among other differences from purely neuropathic ulcers, diabetic foot ulcers in patients with PAD tend to be more severe, are more likely to be infected, are infected by different pathogens, heal less frequently and are more costly to treat, primarily because of a greater number of hospitalizations. All of these factors have implications for the type and success of therapies clinicians employ as well as for the economic burden.
As a result, the economic burden of diabetic foot ulcers complicated by PAD is higher than in DFUs without significant PAD. In 2009 dollars, treatment costs per episode were over $32,000 for foot ulcer patients with PAD.3 This was about 4.5 times the $7,200 cost of treating diabetic foot ulcer patients without PAD, according to the SAGE Group.
A recent report in Drug and Therapeutics Bulletin examined the impact of foot screenings in patients with diabetes in England.4 In 1989, a five-year goal was established there to reduce the amputation rates related to diabetes by one half. Instead, cases of Type 2 diabetes and amputations have increased.
Part of the initiative was to increase diabetic foot screenings as a method to ultimately reduce amputation. During the five-year period, assessment rates rose from 29 percent in 2003-2004 to 83 percent in 2008-2009.4,5 However, no requirement to act on findings existed within the initiative and no evidence exists to demonstrate the screenings had any impact on amputation reduction. When screening was combined with referrals as part of a multidisciplinary approach, researchers observed a positive impact.
The creation of “Integrated Multidisciplinary Specialist Diabetes Foot Teams” has been associated with markedly improved outcomes. In Ipswich, a town in England, the rate of lower extremity amputation decreased from 36.4 to 6.7 major amputations per 10,000 people with diabetes per year over an 11-year period.4,6
The National Institute for Health and Clinical Excellence in Great Britain advises that inpatients who are diagnosed with a diabetic foot ulcer should get a referral to a multidisciplinary team within 24 hours of initial examination of the feet.4,7
Awareness of diabetic foot ulcers and complications is important but even more critical is action in the form of timely referral to providers dedicated to limb preservation. Various authors further support not only the creation of dedicated teams but equally validate the efficacy of the multidisciplinary approach.
In light of these findings, perhaps further research could illuminate how many referrals to a vascular or endovascular service, aside from amputation prevention, result in life saving procedures such a cardiac or carotid intervention in the presence of discovered blockages in respective arteries.
As I alluded to earlier, breast cancer awareness has created an indelible impact in our society. Most women are aware of the importance of being proactive by performing regular self-examinations. In those unfortunate instances when a patient or provider may discover a lump, the request for a referral to an oncologist or other cancer specialist is a foregone action step.
Unfortunately, the same scenario is not associated with the discovery of a diabetic foot ulcer, whether it is complicated by PAD or not. More often than not, a diabetic foot ulcer discovered by a primary care provider meets with a tempered level of urgency and precious time is lost over ensuing weeks. When patients discover an ulcer, they often attempt self-treatment.
Instead of immediate referrals to wound specialists and/or vascular-endovascular specialists, self-treatment by the patient or limited engagement by the provider is more likely.
Allie and colleagues found that more than 50 percent of lower extremity amputations occur without prior vascular testing of any type.8 They noted that tests that were not performed included non-invasive types of testing, such as segmental Doppler, pulse volume recording or ankle-brachial index.
This statistic further illustrates the concept of the lower extremity amputation lottery. Patients with diabetic foot ulcers and wounds related to PAD have their legs and lives in the hands of the provider they happen to be seeing for care. If that provider is not an advocate of limb preservation but views such wounds as an impending indication for amputation, then the patient is certainly in for further complicating issues.
Understanding that a diabetic foot ulcer is a symptom of far more serious underlying conditions is understanding that cardiac artery disease, peripheral arterial disease, heart attack, stroke and diabetic foot ulcers, among the list of diabetes-related complications, all share common factors.
Connecting the dots between these conditions is necessary in formulating a proactive approach to managing patients with diabetes and preventing these catastrophic events. Early screening for PAD, before it becomes symptomatic, is essential in higher risk patients. These patients would include anyone age 50 or over who has diabetes and/or smokes, or those who are over the age of 70, even when health history of the individual is unremarkable. By coupling screening of these patient populations with early referrals to wound care specialists and vascular interventionalists, we can make significant strides toward reducing and preventing catastrophic events such as amputation, heart attack and stroke.
There must be greater accountability in terms of the treatment of diabetic foot ulcers and PAD. We must view these conditions in the same proactive manner as we do with breast cancer if any significant progress is to occur in the realm of limb preservation.
Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.
The author thanks Mary Yost of the SAGE Group and Stephane Courric of Healiance for their contributions to this article.
1. Armstrong DG, Wrobel J, Robbins JM. Are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007; 4(4):286-287.
2. American Cancer Society, American Heart Association, Alzheimer’s Disease Education/Referral Center, American Diabetes Association, SAGE Group
3. Diabetic Foot Ulcers, Peripheral Arterial Disease and Critical Limb Ischemia. Available at http://thesagegroup.us/pages/reports/dfu-statistics.php  .
4. The diabetic amputation lottery. Drug Ther Bull. 2011; 49(9):97.
5. The NHS Information Centre. National Diabetes Audit: 2008–2009 audit analysis. Available at http://www.ic.nhs.uk/webfiles/Services/NCASP/Diabetes/200809  annual report documents/Dashboard 200809 - PCTs ranked nationally.xls .
6. Right Care, 2010. The NHS Atlas of Variation in Healthcare 2010. Available at http://www.rightcare.nhs.uk/atlas/qipp_nhsAtlas-HIGH_261110c.pdf  .
7. The National Institute for Health and Clinical Excellence, 2011. Diabetic foot problems – Inpatient management of diabetic foot problems. NICE clinical guideline 11. Available at http://www.nice.org.uk/nicemedia/live/13416/53556/53556.pdf  .
8. Allie DE, Hebert CJ, Lirtzman MD, et al. Critical limb ischemia: a global epidemic. A critical analysis of current treatment unmasks the clinical and economic costs of CLI. Euro Intervention J. 2005; 1(1):75-84.