Grape, Garlic and Goat Cheese Tartlets for a Summer Book Club Meeting

Grape, onion and goat cheese tartlets 3

Thanks so much to the great women in my book group for giving me the opportunity to do what I love doing more than almost anything else – cook for my friends. I only had the latter part of the afternoon to prepare, having seen patients that day, but it was so much fun spending even those few stolen hours during the work week in my kitchen with the afternoon sun coming in and the radio going.

Here’s the menu I prepared for our little rooftop gathering:

  • Goat Cheese, Garlic & Grape Tartlets
  • Cucumber slices topped with cream cheese, smoked salmon & dill
  • Assorted cheeses and crackers
  • Grapes
  • Castelvetrano Olives
  • Steamed edamame sprinkled with sea salt and fresh ground pepper
  • Pimm’s Cup Pitcher

Fueled by food and drink, we had a spirited discussion on the Middlesteins – a book I didn’t love, but that much of the group did.  Thanks to my fellow members for all the evenings they so generously hosted throughout this past year, and here’s to many more wonderful reads!

grape, garlic and goat chees tartelts 2

Goat Cheese, Garlic & Grape Tartlets

This recipe is modified from a crostini recipe in a lovely little cookbook entitle Small Gatherings – Seasonal Menus for Cozy Dinners by Jessica Strand. It’s a small book of gems for entertaining, complete with prep and timing instructions for stress free entertaining. 

The day was warm and crostini felt too heavy, so I opted to use puff pastry as the base. (If you use crostini, simply slice a baguette crosswise into 1/2 inch slices, brush with olive oil and toast lightly in the oven on 5-7 minutes.) I admit I increased the balsamic vinegar from 1 1/2 tbsp to 3 tbsp – I loved the idea of drizzling a little of that grape infused juice on the tarts.  And I added fresh thyme. 

Makes 24 tarts.

  • 1 box puff pastry (2 sheets)
  • Olive oil for brushing
  • 2 garlic bulbs
  • 4 cups mixed green and red small grapes
  • 1/4 cup walnuts, coarsely chopped
  • 3 tbsp balsamic vinegar
  • 6 ounces goat cheese
  • Fresh thyme for garnish

Preheat the oven to 400 degrees fahrenheit

Thaw the puff pastry at room temp for 45 minutes. Unfold it onto a lightly floured surface and cut into 12 rectangles, Repeat with second pastry. Place rectangles onto a cookie sheet, brush with olive oil, prick with a fork and bake for 10-15 minutes, pressing the pastries down with a spatula if they puff up too much. (If you want to get really fancy, you can brush the edges with a little water, the roll them in to create mini crusts that you then press down with the tines of a fork., but who has time?) Remove to a rack to cool. Keep the oven on.

Using a serrated knife, cut off the tops of the garlic bulbs to expose the cloves. Place in a pie tin, cut side up. Set aside.

In a medium bowl, combine the grapes, walnuts and vinegar and toss to mix well and coat the grapes fully with the vinegar. Transfer the mixture to a small baking dish.

Put the garlic and the grape mixture in the oven side by side. Bake the garlic until it is very, very soft. Bake the grape mixture until the grapes have collapsed and the juices are thick and bubbling. Both the garlic and the grapes should take 35-40 mins.

To assemble, squeeze a roasted garlic clove from its skin onto each puff pastry tart. Using a small knife, spread it as well as you can and then spread a generous teaspoon or two of the cheese on top of each.  (It will be like putting the first layer of icing on a cake – lots of crumbs – and this is where you will think that making this as crostini would have been a much better idea, but don’t worry it will be delicious…) Place a spoonful of the grape mizture on top of the cheese and drizzle a little of the juices atop and garish with a few thyme leaves. Arrange on a decorative platter, sprinkle with salt and fresh ground pepper and serve.

grape, garlic and goat cheese tartlets 5

Bun-ker Vietnamese – The Middle of Nowhere? More Like the Center of My Universe

Bunker 2

In the middle of nowhere, east of East Williamsburg, officially Ridgewood but not really, near the terminus of the Newtown Creek, across the road from an auto salvage yard and just up the road from the NYC Transit Authority is Bun-ker Vietnamese Restaurant, the new center of my universe.

Bunker decor

The place is tacky enough to be incredibly real as only a restaurant started on a shoestring by two brothers can be.  (The out of the way location was to have been a seafood distribution center, but Sandy put an end to that dream.) The walls are covered with bamboo covered wainscoting, little toy soldiers line the window trim and utensils are in aluminum cans on the vinyl tablecloth covered tables, whose benches are made from skateboards and other found wood. If you want filtered water you are welcome to get up and get it yourself from the big orange cooler on the table by the door.

The message is clear – this place is not about the decor. It’s about the food.

And that food is incredible.

Enough said – here’s what we ate –

Crab chips – spicy, light and perfectly accompanied by lime aid with Chia seeds.

crab chips

Bun=Ker Lime Aid with Chia Seeds

Summer Rolls – Shrimp, Pork and Vermicelli. Light, delicious, with fresh basil and a great dipping sauce.

Bun=Ker Summer Roll

Grilled Eggplant with Vermicelli, basil, peanuts, cucumber and roast tomatoes with a light rice wine-fish sauce dressing. Even I, the eggplant non-lover, loved it.

Bun-Ker Grilled Eggplant

Coconut braised Duroc short ribs. (Duroc are a breed of pigs, and these were antibiotic-free, pasture and humanely raised.) Literally falling off the bone.

Bun-Ker Coconut shortribs

Tomato Fried Rice – The perfectly softened garlic clove alone would have been enough.

Bun-Ker tomato fried rice

Ca Ri Ga. The best chicken curry OF MY LIFE, made with lemongrass and coconut, potatoes, and carrots and served with perfectly cooked Roti pancakes for mopping up the sauce.

Bun-ker Chicken Curry

Total tab including tip for this, two lime aids and two vietnames Iced Coffees was $92, which fed 5 of us with ribs leftover to take home.

There were so many dishes we wanted to try but did not – Lemongrass heritage pork loin with fried egg and rice, Banh Mi sandwiches, and the seared turmeric organic salmon just to name a few…

As we were leaving, past the line of patrons standing outside in the rain waiting for a table, Mason was scheming how she would get back for lunch tomorrow. Unfortunately, Mason,Bun-Ker is only open for dinner during the week, but does serve lunch on weekends.

To get there? I’d say take the L  to Jefferson St and take a nice long walk down Flushing Ave to Metropolitan. (Or come with us next time we drive there.)

Arrive early if you want to get a table without a long wait.

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We’re not the first ones to find Bun-Ker – The NY Times, Wall Street Journal, and NY Magazine, among others, beat us to it.  

Is Your Insurer Covering Preventative Services & Contraception without a Co-Pay?

copayYour insurer should be providing certain preventive services, including contraception, without a copay or out of pocket cost to you, even if you have not yet met your deductible for the year. These services include –

  • Breastfeeding support, supplies, and counseling;
  • Screening and counseling for interpersonal and domestic violence;
  • Screening for gestational diabetes;
  • Cervical cancer screening, including DNA testing for high-risk strains of HPV;
  • Counseling regarding sexually transmitted infections, including HIV;
  • Screening for HIV, gonorrhea, chlamydia and syphilis;
  • FDA-Approved Contraceptive methods and counseling –  although your insurer can limit free contraceptive coverage to  generics brands on their formulary
  •  Prenatal Vitamins
  • Mammograms every 1-2 years for women over age 40
  • Well woman visits.

Are you still being asked for a copay for contraception or preventive services? 

Call your insurer and find out why.  (Some insurers have been grandfathered in and still don’t have to pay.)

If you do that and are still not getting the answers you need, the National Women’s Law Center has a toolkit to help that includes templated appeals letters on a range of preventive services.

Still not sure what to do?

Call 1-866-PILL4US or email pill4us@nwlc.org.

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Feed Your Brain – Chilled Avocado Vichyssoise

avocado vichyssoise

This is wonderful chilled soup combines my favorite comfort food – potatoes – with one of the best all around brain foods out there – avocado.

That’s right – avocado is good for your brain. And your mood.  And your heart. And your weight.

According to Drew Ramsey, MD , a NYC psychiatrist who has started an amazing conversation about the role of diet in mood and brain function,  avocados are rich in oleic acid –

Oleic acid …. is strongly linked to a decreased risk of heart disease, diabetes, and depression. It improves insulin sensitivity. Oleic acid is used by the body to create oleoylethanolamide, which enhances memory, induces fat burning, promotes weight loss, and reduces appetite.

Dr Ramsey has begun asking the question – Can you eat for a healthier brain? He has written a book called the Happiness Diet – a way of eating that eliminates processed foods and reintroduces us to the nutrients and foodstuffs that support a healthy mind. It’s a dietary message similar to that we’ve been hearing from food gurus like Michael Pollen and Mark Bittman, but focused on how the modern American diet has impacted our brain and our mood, and how getting back to foods like whole grains, grass fed meat, and  fruits and vegetables can support and even enhance interventions to improve mood.


“Your brain is made of fat”, he says, and he is right, because fats form the precursors for neurotransmitters.  Read Ramsey’s book, and you begin to understand why fat – the right kind of fat – is good for you.  

Of course, the amount of research on this approach is limited, but suggests that Ramsey is on the right track. As a physician, I see dietary interventions as supportive of, but not necessarily replacing, psychiatric intervention, whether it be psychotherapy, or if needed, medication.  I also see no harm in making the kind of dietary changes Ramsey recommends as a first step, along with exercise and talk therapy, when addressing milder forms of mood disorders that don’t require medication.

I’ve written before about the good fats found in whole sheep’s milk yogurt.  Now I’ve added avocado to the list of good-fat foods in my diet.

Avocados are an incredibly satisfying food, not to mention delicious. Add some to your salad. Have a few slices as a side with your lunch or dinner. Grab a spoon and scoop some out for a quick satiating snack.

Or make this marvelous soup.

avocado

Avocado Vichyssoise

Modified from a Recipe from Mark Bittman in the New York Times, one of twelve recipes for cold soups in an article entitled “Soup, Hold the Heat”.   Bittman calls for 1-2 avocados – I used 1 1/2, but that made for a pretty thick soup that required about 1/4 cup water to thin it. Next time I will just use one avocado and see how that tastes. (This was delicious). Don’t skip the cilantro – it is more than just a garnish, it’s essential for the flavor.   

2 tbsp butter
3 Idaho potatoes, peeled and cubed
3 leeks, cleaned and chopped
4 cups chicken broth
1-2 avocados, peeled and coarsely chopped
Salt and Pepper to taste
1/4 cup chopped cilantro for garnish

Melt 2 tablespoons butter in a soup pot. Add potatoes and leeks. Cook for about 3 minutes, stirring, until softened. Add 4 cups stock. Boil, cover, lower the heat and simmer until vegetables are tender, about 20 minutes. Stir in the avocado and puree (I use an immersion blender). Refrigerate till cold, then serve garnished generously with chopped cilantro.

Williamsburg Brooklyn Flea Market

WIlliamsburg Flea Market 1

When warm weather comes, the Brooklyn Flea moves outdoors. Saturdays, its in Fort Greene. And on Sundays, it’s the waterfront in Williamsburg.

For a pretty perfect Sunday at the Williamsburg Flea, arrive early to beat the crowds – the market opens at 10 am – and head straight to Milk Truck Grilled Cheese,

Milk Truck Grilled Cheese

where you will order an All Day Breakfast Sandwich without the grilled onions (OMG….)

Breakfast Sandwich Milk Truck Grilled Cheese

and while it’s grilling, grab a cup of iced coffee from Brooklyn Roasting Company.  Gape at the Manhattan views while you eat your breakfast, and begin to understand the allure of living in this trendy section of Brooklyn.

Water from Williamsburg FleaBut enough gaping, there are treasures to seek.

Metal chairs Williamsburg Flea Market

WIlliamsburg Flea 3

WIlliamsburg Flea letters

WIlliamsburg Flea 4

Lucky for you, your friend Amy is with you – she has the artist’s eye for flea marketing. After you passed through the best stall there  – Dan’s Parent’s House (how much do you love that name?) – without finding a thing, she zeroes in the very coolest things there. Like these colored metal coils (she’ll use the big red ones for Sabbath candle holders, and make a necklace out of the rest)-

Williamsburg Flea 2

and these red saws (She found the two best and will hang them on her wall in some cool arrangement)

Red Saw

But don’t be jealous, because you found this – a real working NYC parking meter!  Timed baking will never be the same in your kitchen…

NYC Parking Meter 2

Spend another couple of hours wandering, trying on clothes, wishing you needed a new dining room table because that one with the metal pipe fitted legs would be so perfect in your apartment, and in Amy’s case, regretting that you didn’t grab that red typewriter when you first saw it because now that nice young man is carrying it away (and at a great price too…)

Consol yourselves by leaving the now crowded market to head up the street to Artists and Fleas,

Artist & Fleas

a place where the uber-hip artists have taken what the rest of us miss and turn it into treasures. Like these game board journals at Another Work in Progress-

Game board vintage journals

and this gorgeous dress that had me wishing I were 18 again.

Dress artists and Fleas

When I say uber-hip I mean it. This place even has a DJ spinning vinyl jazz and samba –

DJ Artists and Fleas

Too cool even for me.

Which means it’s time for lunch –  in our case a delicious lobster roll at nearby Rosarito Fish Shack.

Lobster roll

 Of course, you could have headed back to the Flea Market to one of the many restaurant booths there, but a comfy seat and a cold drink under a spinning ceiling fan seems more in order on a warm afternoon before heading back home to Manhattan.

All in all, a pretty darned near perfect day.

I say darned-near because of the one thing we did not do, but which you must do when you go to the Williamsbug Flea, and that is to take the ferry there.

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The Brooklyn Flea Market on Sundays is in Williamsburg. (And now in Philly!!!)  On Saturday’s, it’s in Fort Greene. In the winter, it’s indoors at the Williamsburg Savings Bank.

The EHR is the Frankenstein of Modern Medicine

Frankenstein EMRWe created the electronic health record, but if we can’t figure out how to contain it,  it may just destroy us.

A recent study at Johns Hopkins University indicated that hospital interns — physicians at perhaps their most formative stage of training — spend only about 12 percent of their time interacting with patients. By contrast, they spend 40 percent of their time — more than 3 times as much — interacting with hospital information systems. The flesh-and-blood patient is getting buried under gigabytes of data.

The Drawbacks of Data Driven Medicine by Dr Richard Gunderman in this month’s Atlantic Monthly.

A must read for docs and patients alike.  Comments section rocks too.

Birth Control – It Works.

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A nice infographic from the Alan Guttmacher Institute.

These simple statistics demonstrate how effective contraceptive use can be. They also categorically refute claims by anti-contraception activists that access to contraception somehow leads to more unintended pregnancies and subsequent abortions.

Birth control works.

So use it.

“Birth control” means any effective method, including condoms, diaphragm, sponge, pills, patches,  implants, rings, shots, and IUDs.  The most effective methods on a population basis are the long acting methods – IUD’s and implants. Which does not mean you should stop your pills if you are an effective pill user, but means that in some women, longer acting methods make for better compliance.

Effective does not include withdrawal, and in most women, timing. Yes, I know – a few of you use timing well.  If so, go for it.  But before you do, remember the old joke – What do they call couples who use rhythm for birth control?

Parents.

Size Too

“Size Too” by Ariel Sobel

For every high school girl out there feeling like she’s not the right size for a prom dress.

I told you I’m a size two
And that’s the truth
I’m a size too powerful to fit your standards
Too chill to be wound up like lanyards
Too smart to have hair this light
And too fast not to be in flight
Too beautiful not to shatter your sight…
A fabulous poem and performance.

 

Potato Leek Soup

Potato Leek Soup

When I was a very little girl, I was sitting at the kitchen table eating mashed potatoes, and my mother turned to our neighbor, who was visiting at the time, and said, “She’d eat mashed potatoes till the cows came home”.

I’d say that still holds true.

Except sometimes I eat my mashed potatoes in a soup.

This is an exceedingly simple soup that is  lighter in calories than mashed potatoes, but just as satisfying for this half Irish girl who is still wondering where she’ll put those cows if they ever show up on her doorstep.

Postato Leek Soup

This recipe is from Richard Olney’s cookbook Simple French Food,  via one of my new favorite blogs, A Serious Bunburyist. There is no cream in this – it does not need it. But that butter at the end? C-est manifique!

Ingredients

  • 2 quarts salted boiling water
  • 1 pound potatoes, peeled, quartered lengthwise, sliced (we used Yukon golds)
  • 1 pound leeks, tough green parts removed, cleaned, finely sliced
  • 3 tablespoons unsalted butter
  • salt and pepper to taste

Instructions

Olney has you add the vegetables to the salted boiling water and cook till the potatoes are soft and mashable. I was dying to saute those leeks up first in the butter and then add the water (or maybe chicken stock) and the potatoes, and then maybe a bouquet garni, but I really had no say in the matter as I was still at work when Mr TBTAM started cooking. By the time I arrived home, the leeks and potatoes were done,  so I just got out the old immersion blender and went to town.  Maybe someday I’ll try a fancier version, but this was pretty close to perfect as far as I’m concerned.

Serve hot or cold with a generous sprinkling of sea salt and pepper to finish.

Dawn Powell on Happiness

Dawnpowell_1914

Brilliant societal analysis from Dawn Powell (1896-1965).

What most people wanted was the happiness of having what other people wanted. Then they had brief moments of an inferior happiness when they only got what they themselves but nobody else wanted. This rather spoiled things.  Some people made mistakes in their opinion of what other people wanted, but if they didn’t  find out they managed to be happy , maybe wondering a little once in awhile what everybody wanted this for.  Others wasted so much time trying to have what other people wanted that they never knew they were perfectly happy without it. The biggest jolt in growing up was to discover that that you    didn’t like what others liked and they thought you were crazy to like what you liked.

I’d never heard of Powell till my book club read her book “My Home is Far Away“, from which this quote comes. (Thanks, Stacy, for suggesting it.) This is pretty much par for the course for Powell, who never gained the prominence many think she deserved during her lifetime, for as Gore Vidal wrote  –

For decades Dawn Powell was always just on the verge of ceasing to be a cult and becoming a major religion.

Powell was born in Mt. Gilead, Ohio in 1896, but ran away from home at age 13 and lived most of her adult life in Greenwich Village, where she was part of the Bohemian scene that included EE Cummings and John Dos Passos. She published 16 novels, nine plays and numerous short stories, not a few of which were acerbic Manhattan-based comedies that have been called funnier than Dorothy Parker’s and virtually all of which were out of print when she died in 1965.  Powell was rescued posthumously from obscurity by Vidal and then music critic Tim Rice, who published her bio in 1998 but failed to sell her diaries in 2012 (although Columbia University eventually purchased them in March of this year). According to the Library of America, more of Powell’s books are now in publication than at any time in her life.

I plan on reading more.
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More on Dawn Powell

Pic – Dawn Powell, 1914. From Wikipedia

Music & Medicine – All Schubert Concert

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Looking for something to do tomorrow (Wednesday May 22) evening? Come hear the Weill Cornell Music in Medicine Orchestra and Chorus perform an all Schubert Program at the Caspary Auditorium (that funky blue dome on the Rockefeller University campus).

I’ll be singing in the soprano section.

Angelina, BRCA, Mastectomies, etc…

Angelina_Jolie_Cannes_2011

In a beautifully written editorial in the NY Times entitled “My Medical Choice” Anjelina Jolie has come out publicly as a carrier of the BRCA 1 gene, which places her at high risk for both breast and ovarian cancer.  She has undergone a prophylactic nipple-sparing mastectomy with plans for future removal of her ovaries to prevent ovarian cancer.

I choose not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. It is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.  Life comes with many challenges. The ones that should not scare us are the ones we can take on and take control of.

Kudos to Jolie for choosing to tell her story in such a measured and informative manner. Having referred dozens of high risk women for BRCA testing, only to see them avoid it year after year, I for one  hope that Jolie’s story will encourage women at high risk to get screened.

But I also recognize that not every woman with a suggestive family history wants to know her BRCA status.

And that, too, is a choice.

What Most of You Need to Know

For the overwhelming majority of the rest of the women I see, and for almost  all of you reading this, the most important thing you need to know is buried within Jolie’s  editorial, and it is this –

Only a fraction of breast cancers result from an inherited gene mutation.

About 2% of women have a family history that suggests the possibility of BRCA mutation,  and only about 1/10  of one percent of women carry a BRCA gene mutation.

Thus, Jolie’s story, while compelling, is medically irrelevant to almost all women. But for a very few, it may be lifesaving.

Should you consider BRCA testing?

Not unless you yourself have had pre-menopausal breast cancer or have had ovarian cancer, or  have a strong family history of breast/ovarian cancer.  From the NCI, here are the recommendations for screening based on family history –

For women who are not of Ashkenazi Jewish descent:

  • two first-degree relatives (mother, daughter, or sister) diagnosed with breast cancer, one of whom was diagnosed at age 50 or younger;
  • three or more first-degree or second-degree (grandmother or aunt) relatives diagnosed with breast cancer regardless of their age at diagnosis;
  • a combination of first- and second-degree relatives diagnosed with breast cancer and ovarian cancer (one cancer type per person);
  • a first-degree relative with cancer diagnosed in both breasts (bilateral breast cancer);
  • a combination of two or more first- or second-degree relatives diagnosed with ovarian cancer regardless of age at diagnosis;
  • a first- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis; and
  • breast cancer diagnosed in a male relative.

For women of Ashkenazi Jewish descent:

  • any first-degree relative diagnosed with breast or ovarian cancer; and
  • two second-degree relatives on the same side of the family diagnosed with breast or ovarian cancer.

What about prophylactic Mastectomy?

Mastectomy was not Angelina’s only choice.  Mastectomy is effective at reducing the risk for  breast cancer, but breast cancer mortality is not impacted due the effects of aggressive screening and excellent treatments for breast cancer when it is diagnosed in BRCA carriers who choose not to have a mastectomy on a preventive basis.  Thus, Jolie  could have opted for aggressive screening with breast mri and/or use of medication (tamoxifen or raloxifene) to cut her risk of breast cancer in half. But with the option for nipple sparing surgery, mastectomy appears less a barbaric operation than in the past, with only a small increase in risk for leaving the nipple behind.

The use of mastectomy is increasing, not just among BRCA carriers, but among women with early breast cancer or pre-invasive disease (DCIS and LCIS) that places them at higher risk for invasive cancer in the future.  I for one worry that mastectomy may be getting over-used, and hope that Angelina’s story will not result in more women having surgery than is necessary.

What about Ovarian Cancer Protection?

As a gynecologist, I’m particularly concerned about ovarian cancer in BRCA carriers.

Angelina’s decision to remove her ovaries and fallopian tubes offers her the best odds of avoiding ovarian cancer, the disease that took her mother’s life.  Unlike mastectomy, which prevents cancer but does not reduce mortality, oophorectomy does reduce mortality form ovarian cancer.  Because the truth is, we have nothing to offer to women to effectively screen and diagnose ovarian cancer at early stages  (although we offer it, ultrasound is not effective screening on a population basis), and treatments are just not as good as what we have for breast cancer.  So BRCA carriers are offered prophylactic BSO in their 40’s or once childbearing is completed.  The procedure itself can often be done as an outpatient  laparoscopic surgery.

We are beginning to understand that ovarian cancer may actually originate in the fallopian tubes. Research is underway to determine if removal of the fallopian tubes alone might provide similar protection as removing of both the ovaries and tubes.  It’s too soon to say how that will play out, but we are hopeful.

What most women do not realize is that we do have prevention for ovarian cancer.  It’s called the Birth Control Pill, and taking it can lower the risk for ovarian cancer by 80%.

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More reading

  • CNN – What Angelina Forgot to Mention.  A Must Read.
  • NYTimes – an excellent discussion on the rising use of mastectomy for breast cancer prevention
  • NPR Blog – Peggy Orenstein raises concerns about women generalizing Jolie’s experience to the average woman not at increased breast cancer risk.
  • LA Times – Anna Gorman, another BRCA carrier, tells her story
  • Prophylactic Oophorectomy in BRCA Carriers
  • Huffington Post – Good Video segment including interviews with breast experts and survivors.

Ms Jolie’s image used with permission from Wikipedia, Source: George Biard

A Joyful Springtime Concert – You’re Invited

CECELIA-CONCERT2

We just had our final rehearsal last night with the orchestra – so much fun!  I’m really excited to be singing this wonderful music with my dear friends and fellow members of the Collegiate Singers. Two of the pieces are in praise of music and of St Cecelia, the patron saint of musicians and singers. The rest are marvelous English Glees.  The orchestration includes gorgeous cello, flute and oboe solos, and our solo singers are truly wonderful.   If you’re looking for a lovely way to spend a spring evening, do join us tomorrow, May 15 at 7:30 pm at the Church of Christ and St Stephens, a  little gem of a venue with great acoustics on W 69th st just east of Broadway.

New Pap Management Guidelines – Balancing Benefits and Harms of Cervical Cancer Screening

Sunrise over the Mississippi - NOLA
Mississippi Sunrise in NOLA

It’s fitting that this year’s ACOG meeting was held in New Orleans, because navigating the 2013 ASCCP Pap Smear Management Guidelines presented there feels like trying to make my way through the Mississippi bayou. The guidelines include 18 different algorithms encompassing almost any combination of pap and HPV abnormality we docs are likely to encounter among our patients.  But all tributaries lead to the same place, where we achieve optimal reduction in cervical cancer with minimal harm.  

Cervical cancer prevention is a process with benefits and harms. Risk cannot be reduced to zero with currently available strategies, and attempts to achieve zero risk may result in unbalanced harms, including over treatment. …optimal prevention strategies should identify those HPV-related abnormalities likely to progress to invasive cancers while avoiding destructive treatment of abnormalities not destined to become cancerous. Adopted management strategies provide what participants considered an acceptable level of risk of failing to detect high-grade neoplasia or cancer in a given clinical situation.

I’m not even going to try to spell out everything in the guidelines, which come from the American Society of Colposcopy and Cervical Pathology (ASCCP), except to say that they represent further movement away from aggressive screening and treatment of pap smear abnormalities, especially in younger women, in whom treatment carries small but real childbearing risks. The guidelines are increasingly reliant upon HPV testing to determine who and how often to screen, and when to treat.  They also acknowledge the role of testing for HPV 16 and 18 as a way to be sure that those women with adenocarcinoma of the cervix (which is less likely to show up as cancer on a pap smear) are identified and treated. From the guidelines –

 ASCCP CHANGES2

What should you expect?

  • Less pap smears, for sure. Women should start screening at 21 and have paps every 3 years until age 65 (assuming, of course, that her paps remain normal).  There is no place for HPV as routine screening in women under age 30, as most of these women will acquire HPV one or more times by that age, with little consequence.  HPV testing is used in this age group to manage abnormal paps and to follow those with prior pap abnormalities, but that’s it.  Women age 30 and over have the option of pap with HPV co-testing – if both are normal/negative, she may go up to 5 years before her next pap.
  • Little treatment of CIN1. CIN 1 represents HPV infection but is not a true pre-cancer and usually will resolve within two years. (If it does not resolve by then, treatment is an option.)
  • Less use of colposcopy in younger women with mildly abnormal paps, even if HPV testing is positive. In women ages 21-24, one may repeat the pap with HPV testing at 12 months rather than go to immediate colposcopy for mild pap smear abnormalities (ASCUS and LGSIL).
  • Continued decline in treatment for CIN2. Most CIN2 will resolve without treatment. (I’ve been backing off on cin2 treatment for some time now in younger women and indeed most lesions resolve.)
  • The option to observe CIN3. I don’t know how often any of us are going to use that option, though I admit to having already taken it occasionally in younger women with focal CIN3 lesions that were removed at colposcopy.
  • Increased interval pap followup in women who have had colposcopy or treatment for CIN2-3.
  • Increasing use of HPV 16/18 testing to identify those women with mild pap abnormalities who may need immediate colposcopy.

Confused? There’s an App for that! 

IMG_8137

In a very smart move, ASCCP has launched an app for providers wondering just what to do with those abnormal pap results. It’s called ASCCP Mobile, it costs $9.99 and it’s really cool.  Let me show you how it works-

Let’s say you have a 27 yo, non-pregnant patient with an LSIL Pap and HPV+. Just enter the info, click next  and, as Emeril would say – Bam! You’ve got the appropriate algorithm for her right there on your screen!

IMG_8138

 Click next steps, and enter her colpo result, which let’s say was CIN3 and Bam!  You are advised to treat her, and to perform 12 month pap/HPV co-testing for follow up.

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Of course, you could have pulled out the guidelines and found the right algorithm there, but this is a lot more fun.

ASCCP Mobile is not so much a recipe for patient management as it is a navigator through a complex algorithm that requires a lot more than just tapping a screen to understand and execute. I encourage you to read the actual guidelines article (links below), which provides the background and summarizes the evidence supporting each of the recommendations.

And lest you think we’ve just distilled gynecology into an app, remember that not every patient fits an algorithm. Not all patient populations are suited to follow-up, particularly those who may have spotty or intermittent care. Fortunately, most of the algorithms provide options for management that will allow almost any woman and her provider to come to a management decision that’s right for her.

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