5-Hour Energy “Pinkified” for Breast Cancer – Really?…

The Komen Foundation set the bar low when it partnered with Kentucky Fried Chicken to fight breast cancer, urging women and their families to buy the fat-laden meals despite the fact that obesity increases the risks of breast cancer.

Now the Avon Foundation has slid right under that bar by teaming up with the makers of 5-Hour Energy Drinks to sell pink energy lemonade, with a portion of the proceeds going to fight breast cancer.

Really?….

This is, after all, the same Energy Drink that has been linked to 13 deaths over the past four years and is currently being investigated by the FDA. The drink that comes with a warning label stating “Do not take if you are pregnant or nursing, or under 12 years of age. If you are taking medication and/or have a medical condition, consult your doctor before use.” And despite claims that it only contains as much caffeine as a cup of coffee, the label also warns ” Do not exceed two bottles of 5-hour ENERGY® shots daily, consumed several hours apart”.

This is the drink we need to be buying to help fight breast cancer?

What’s next –  Pink cigarettes?

HPV in Menopause – Old Infections or New Relations?

Menopausal couple cropped
New love comes at all ages.
So can HPV.

When HPV occurs in the menopause, is it due to reactivation of a previous HPV infection or a newly acquired infection?  That’s the question asked, but not properly answered in this doc’s opinion, by a new study published this week in the Journal of Infectious Diseases.

Researchers performed HPV testing in 843 women age 30-60, and found an increased prevalence of HPV infections among women in the peri-menopausal age group who also reported having had >5 lifetime partners, but not necessarily a new partner within the past 6 months. They concluded that this second lifetime peak of HPV infections (the first peak occurs in the second decade) was due, not to new HPV infections, but to infections acquired in the earlier years that were now re-emerging with older age and waning immunity.

The fact that we have not seen this peri-menopausal HPV peak in prior population-based studies, they say, is because most women in this age group until now have not had so many sexual partners.

The study’s findings contradicts what we are now telling women, which is that most HPV infections permanently clear within two years of an initial infection that occurs primarily during the second and third decades.

Erroneous conclusions based on a flawed study design

I take strong issue with the study’s conclusions, based on over two decades taking care of peri-menopausal women in a country where 50% of marriages end in divorce.

The flawed conclusions of this study stem from what I believe to be a flawed methodology – namely using 6 months as a cut off for defining women as having had a recent new partner, an artificial categorization that makes no sense socially or biologically. As a result, the researchers may have missed much of the important new sexual activity in their cohort that could explain an increase in HPV infection around the age of menopause.

Sex, HPV and the Middle-Aged Woman

Many women in their middle years have new relationships through divorce, dating and often, remarriage. HPV infection can occur at any time in a recent relationship, not just in the first 6 months (a part of which time many couples use condoms). These infections can persist up to 2-3 years before they clear and be diagnosed any point in that time frame.

In my own clinical practice, the overwhelming majority of HPV infections in this age group occur in women who have had a clear change in partnership within the past 1-5 years. Not surprisingly, theses HPV infections clear in the same 12-36 month time frame as the infections I’m diagnosing in the younger crowd.

Remember too, that it is at middle age that some of the husbands will start to wander – bringing home a new infection to a woman who has not had a new sexual partner in decades. The study does nothing to address this possibility. Not that any study can, of course, but you get my point.

A better study design would have been to ask how long the subject has been in her current relationship , and correlate that with HPV prevalence.

Bottom Line –

The study raises interesting questions, but unfortunately its design limits its conclusions, which to this clinician don’t make sense given what we know about HPV infection and the social lives of women.

While we cannot completely discount the possibility of reactivation of dormant HPV, this study, in my opinion, does little to answer the question it raises.

Unfortunately, the publicity around this study is sure to drive anxiety among every menopausal woman out there, especially as we are now telling them that they can back off on pap smears if theirs have been normal up till now. (I myself am not 100% comfortable with the new pap recommendations, by the way...)

What if you have a positive HPV and have not had a new partner?

I see two possible ways that a women can have HPV and not have a new HPV infection.

One is a longstanding persistent HPV infection that is only now causing precancerous changes, which as we know can take decades to appear. Is this reactivation of a dormant HPV infection or just delayed detection? After all, we only recently began testing for HPV, so unless we have a prior negative test, it’s hard to say, isn’t it?

The second is that menopause itself can lead to low grade pap abnormalities related to estrogen deficiency rather than true pre-neoplastic changes.  In women without HPV, these are so called false positives. But in women who may have a persistent HPV infection, this estrogen-deficient pap may be the first time she has ever had an HPV test.

The important point with these two scenarios is that not every HPV infection necessarily comes from a new partner (or a wayward husband).

Which is good to know.

Home Tours – My Secret Addiction

The Ultimate Online House Tour
The Ultimate Online House Tour

I admit it. I’m a house and home voyeur.

It was something I discovered while house hunting in Philadelphia over two decades ago – there is nothing more fun than going to an open house.

Not because I want to spy on others, though that’s part of the fun.  But what I really want to do is get design ideas. See how real people in real spaces make it work. Look how they arranged their living room! What a clever closet!  Is that really an IKEA kitchen? It looks gorgeous!

In the old days, my husband and I would sometimes spent entire Sundays at open houses, even after we were no longer in the market for a home. As our family grew, and time became more precious, I was forced to confine my house tour voyeurism to Halloween – ostensibly being a good parent accompanying my small daughters, what I was really doing was finding out what the folks on the 10th floor were doing with their place.

Unfortunately, that ruse lasted only so many years, at which point my kid and her friends refused to let me join them trick or treating, and the neighbors began to look at me funny when I showed up alone at their front door without a costume…

Fortunately, just around that time, I discovered Apartment Therapy, and I was off and running in the work of online home tours.

Now I can practice my addiction in the privacy of my own home, where I will sit up till all hours of the night checking out how the rest of the world lives. No one has to know. No one gets hurt.

And I get my fix.

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Home Tours Online

Here are just a few of the places I go for my fix of other people’s spaces –

  • NYTimes Real Estate Section – Let’s face it – we’re all addicted to the Time’s Real Estate section. For most of us, it’s like reading the bios of the lottery winners. Pick a neighborhood, drag the price range bar as high as it will go and enjoy the fantasy.
  • Apartment Therapy – Young and hip folks and the places they inhabit. It frustrates me that it takes so many clicks to get into a given tour, but once you’re there it’s almost always worth the journey. The spaces can be anything from an early post-college shared space to a settled family home. Some are amazing, others more ordinary, and occasionally, some disappoint. That’s what makes them real.
  • The Design Files Daily – Australian Homes.  The site is clean and easy to use, and has convinced me that I need to visit Australia and maybe live there if this is the kind of light and color that inhabits that country.
  • Design Sponge – Sneak Peeks – I feel really old and terribly unhip looking at these spaces.Where do these kids get their eye for things? Of course the site is run by a very hip young woman from Brooklyn. Which I will never be.
  • Ikea – I never stop loving how stuff so cheap and flimsy can look so good. The room tours are always inspirational, and the clutter very real looking.  One of these days I’ll show you how we transformed our cottage using IKEA furniture. Of wait, that would be a house tour, wouldn’t it?
  • Home Designing – Modern design home tours; really fabulous ideas here that I will never be able to afford to do. Try to ignore the ads – they’re everywhere.
  • W Magazine – Tour the homes of the rich and famous. Or not.
  • Martha Stewart – You can tour all of Martha’s own homes, those of her editors, and then by category – suburban, waterfront, etc. Some great spaces here, though trending to traditional. Once you’ve entered a tour it’s hard to get back to the tour home page, so I recommend you right click on the house tour link and open each tour in a fresh browser window so you can find your way back home. Just like Martha did from prison.

Lemon Grass and Rice Noodle Fish Soup

This soup from David Tanis City Kitchen column in the  NY Times is a revelation.  The noodles, mussels and squid are perfectly cooked and tender, providing contrasting textures with the raw vegetable and herb garnishes. The broth will warm the cockles of your heart, and the flavors will lighten your soul.

Mr TBTAM made this soup for dinner last Thursday, despite my objections that it was too much work for a weeknight on which I had a lot of work to do.  I was so glad he didn’t listen and went ahead and made it without me, even cleaning up the kitchen afterwards himself.

My friend Allen was glad too – he downed a bowl of the soup at 10 pm when he and Jane arrived from Minneapolis for a visit.

And I was even gladder two days later, when Mr TBTAM and I shared what was left of the soup for a quick lunch before heading to a Sunday matinee (The Anarchist – Patti Lupone was  fabulous, unfortunately the script was not.).

So go ahead – Make this soup.

You’ll be glad you did.

(Recipe here. We used chicken rather than fish broth. I left the chiles out of my garnish – it was spicy enough without it.)

A House Call From Hell

Open Culture points us to Koji Yamamura‘s powerful animation of Kafka’s nightmare short story “A Country Doctor”.

I was in great difficulty

So says the doctor as he tells us of how he was called in the middle of a nighttime blizzard to attend a dying boy, a house call that will ultimately force him to face his own shameful and tormented soul.

His own horse dead from overexertion in the severe winter, the doctor is forced against his will to leave his maid in the arms of a mysterious groomsman, the only person who will lend him a horse on this terrible night.

Arriving at the sick house, the doctor at first dismisses the boy’s illness as a short-term coffee overdose, ranting on about patients who torment his unnecessary emergency calls, his low pay from the district and the uselessness of his calling. Despite this, he gives the family a prescription for the boy because

it is easy to write prescriptions, but difficult to come to an understanding with people.

When it appears this is not enough to satisfy them, the doctor heads back to the sick bed only to discover that the boy is actually dying from a maggot infested wound that will become a flower, and for which there is no cure. At that point, he is surrounded by the villagers and his employers, exposed, literally, as the useless failure that he is, stripped of his clothes and laid in the bed with the dying boy.

Take off his clothes and he will heal.
And if he doesn’t cure, then kill him.
It’s only a doctor, only a doctor.

After convincing the boy that his wounds are actually not as bad as those of many others, which actually comforts him, the doctor escapes, naked on horseback through the storm, past the villagers and back into his home, accompanied by the chanting of children, who sing –

Enjoy yourselves, you patients. The doctor has lain in bed with you.

Wow.

In this short tale written almost a century ago in 1916, Kafka has embodied the inherent conflict between the humanly imperfect doctor and the society which both respects and ultimately despises him for his inability to save them all from death – for in modern society, the doctor has replaced the priest as the road to salvation.

Always demanding the impossible from the doctor. They have lost the old faith. The priest sits at home and tears his religious robes to pieces, one after the other. But the doctor is supposed to achieve everything with his delicate surgeon’s hand.

He also shows us the toll this conflict can take on the individual doctor, who has clearly become burnt out and as a result, useless to his patients.

I’ll never come home at this rate. My flourishing practice is lost. A successor is robbing me, but to no avail, for he cannot replace me. … Betrayed! Betrayed! Once one responds to a false alarm on the night bell, there’s no making it good again—not ever.

In some ways, the story portends the decline, not just of an individual doctor, but of the medical profession itself.

Called to society’s side, we fail to see the real problems in front of us, and even when we do, we are ill-equipped to cure them. But with the rise of the internet, we are being stripped bare of our robes of power, and sent on our way, while others who represent the gods of technology step into our place as the beacons of hope and immortality. If Kafka’s truths are indeed as timeless as they seem, these new gods will ultimately fail as well.

Then again, I may just be having a bad day.

Latkes 2012

It’s Hanukkah, and in our family that means latkes.

This year, our market seemed to be having a bit of a potato shortage, so I ended up using mostly Russets instead of my usual favorite Yukon Golds. What I did not realize was the the Russets have very little water in them,  so when I did my usual potatoes-in-the-dish-towel-squeeze I ended up with a very dry potato mixture that required 4 eggs to stick together!

Lesson learned  – If you use Russets, don’t drain the potatoes or onions after shredding them. Bittman says the Russets make better latkes than the more waxy varieties, but I still like the Yukon golds the best.

Despite my love of old traditions, I also think the food processor makes better shreds than the hand grater.

This years latkes were still delicious, despite (?because of) the extra eggs. Then again, there’s not much one can do to ruin a latke.

Here’s my recipe.

Penne with Brussels Sprouts, Chili and Panchetta

I take full credit for this dinner, because when my husband called me at work to ask “Shall I make that brussels sprouts pasta recipe from Melissa Clark’s column in the Times?”, I immediately said “Yes!”.

I thought it was delicious served with grated Parmesan, although, given the bite this dish packs,  it was even better the next night with a dollop of sheep’s milk yogurt. (Yes, I am addicted to the stuff.)

Recipe here.

Time-Based Billing – It Won’t Waste Your Time

In a NYTimes Op-Ed piece entitled “A Shortcut to Wasted Time“, internist Leora Horowitz bemoans the erosion of the medical record, once a means to communicate about a patient’s health, now merely an electronic repository for the minutiae of a medical encounter required for docs to get paid for the work they do. Because, as she simply puts it –

Doctors are paid not by how much time they spend with patients, how well they listen or how hard they think about what could be wrong, but by how much they write down.

In her editorial Horowitz tells us that she spent 40 minutes counseling an anxious patient who was neither sleeping nor eating, and how she was unable in the current payment system to bill for that visit –

Last week, I spent 40 minutes with a patient who had just placed her mother into hospice care. My patient was distraught, not sleeping, not eating. I gave her some advice, but mostly I just listened. By the end of our visit, she was feeling much better. But I wouldn’t be able to bill much for that visit based on my documentation: I didn’t review her medical or family history, conduct a review of organ systems or perform a physical exam.

What the payment system tells me to do is to cut her off after 10 minutes, listen to her heart and lungs and give her a sleeping pill. Which doctor visit would you prefer?

There are many of us who agree with Dr Horowitz about the erosion of the medical record in the era of the EMR.

But I have to disagree with her when she says she would not be able to bill much for that patient’s visit.

Because there is a simple and ethical way within the current system to easily document and get paid for medically necessary encounters such as the one Dr Horowitz describes that does not involve check off boxes, cutting and pasting, or even a physical exam.

It’s called time-based billing.

When you spend >50% of the encounter in counseling and/or coordination of care, time is the key factor in deciding the level of service. Not history, exam or medical decision making. Just time.

How do I know this?

Because I’ve been the billing compliance leader in my department for almost a decade, reviewed hundreds of my colleagues’ charts for coding accuracy, and sat through more lectures on coding than anatomy classes. If there was a GME approved fellowship in medical coding, I’d be running the damned thing.  That’s how I know.

Plus, I asked a certified medical coding expert.

Time based billing is like the WAYBAC Machine for the Medical Record

You simply document the chief complaint of the patient and the extent to which history and exam may have been done, what you talked about, including advice given and management plan, how much time you spent doing it, and indicate the diagnosis to support the medical necessity for your work.

Here’s when and how you do it, straight from the CMS Manual –

C – Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling

Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

EXAMPLE
A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.

In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.

In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

How Dr Horowitz could have billed that encounter

For Dr Horowitz’s patient, there were real complaints that the patient presented with and she probably did review (and update) family history.  There were also some elements of exam – Constitutional (general appearance) and certainly Psychiatric (mood). She could document all of that, the total time she spent with the patient and the fact that more than 50% was spent (listening and) counseling, as well as a summary of the discussion points and plan.

Per CPT guidelines, the average time allotted to CPT 99215 is 40 minutes. So, I’d suggest she bill 99215 with a diagnosis of depression/anxiety, insomnia and weight loss.

Which brings up another problem

Of course, using a high level code like 99215, Dr Horowitz should be prepared for her chart to be audited, since insurers increasingly don’t want to pay for high level visits.

Which is whole ‘nuther post for whole ‘nuther day…

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WAYBAC machine image from Wikipedia

More on Mammogram Over-Diagnosis

Surgeon/scientist Orac has written a wonderful in-depth analysis of Bayer and Welch’s recent NEJM article on 30 years of mammography screening. I strongly recommend you read Orac’s post, entitled “Cracks  Spin vs Science on Mammography”,  if you are interested in exploring this topic further.

The post, like most of what Orac writes, is incredibly informative but very long (I thought I was verbose, but he beats me every time), so allow me to summarize the points I took home from reading it –

  • The NEJM study’s finding of over-diagnosis is in line with prior studies, strengthening it as a real possibility, but does not excluding the possibility that both studies have as yet unidentified biases that lead to the finding of over-diagnosis.

After reading this study, my first thought was: Here we go again. My second thought was: Wow. The result that one in three mammographically detected breast cancers might be overdiagnosed is eerily consistent with a study published three years ago that looked at mammography screening programs from locations as varied as the United Kingdom, Canada, Australia, Sweden, and Norway, which I discussed at the time it was released. The consistency could mean either convergence on a “true” estimate of overdiagnosis, or it might mean that both studies shared a bias, incorrect assumption, or methodological flaw. If they do, I couldn’t find it, but it’s still an intriguing similarity.

  • The study used SEER data, which is not perfect, and made some assumptions that could have over-estimated the rate of over-diagnosis, again not perfect and possibly over-estimating, but not eliminating, mammogram’s rate of over-diagnosis.
  • Using the rates of breast cancer in women under 40 as a surrogate for breast cancer mortality rates in un-screened women over age 40 may not be appropriate, as the biology of breast cancers in younger women is likely to be very different than those in women over 40. Unfortunately, there is not a better comparison group that could have been used instead.
  • The study ignores the possibility that stage creep could account for the lack of decline in later stage breast cancers of time. This is a phenomenon  in which previously so-called early cancers are more likely now to be classified as later stage due to better detection of tumor cells in axillary nodes using sentinal node biopsy. This is a concept of which I had not been aware.

One study suggested that the stage migration rate was as high as one in four; i.e., 40% of patients having “positive” axillary lymph nodes with SLN biopsy compared to 30% having positive nodes using axillary dissection. Another studyreported similar results. How this would affect Welch’s analysis is hard to tell, and correcting for it is probably not possible using the SEER database, particularly given that the extent of “up-staging” is not fully known yet. Be that as it may, an increase in the apparent incidence of patients with positive lymph nodes would increase the apparent incidence of advanced disease and decrease any decline in the incidence of advanced disease. How large this effect is, I don’t know, but it would suggest that the rate of over-diagnosis is lower than what Welch estimates. How much lower, or whether stage migration is even a significant factor, I don’t know, but I wish that Welch had at least mentioned it.

  • Could mammogram be victim of the so-called  “the decline effect”?

Basically, this is a term for a phenomenon in which initial results from experiments or studies of a scientific question are highly impressive, but, over time, become less so as the same investigators and other investigators try to replicate the results, usually as a means of building on them.

Orac also takes on the extremists on both sides of the issue – those that would use the study as fodder to paint mammograms as evil – or as he puts it,  “The cranks have had a chance to discover the study” – as well as those in the medical profession who refuse to accept any criticism of mammography – one actually calling it “malicious nonsense”.

…the Bleyer and Welch study is simply more evidence that the balance of risks and harms from mammography is far more complex than perhaps we have appreciated before. It’s very hard for people, even physicians, to accept that not all cancers need to be treated, and the simplicity of messaging needed to promote a public health initiative like mammography can sometimes lead advocacy groups astray from a strictly scientific standpoint.

It has weaknesses and might well overestimate the rate of overdiagnosis, but overdiagnosis is a real phenomenon….As I said, it’s hard for many physicians to accept that not all cancer necessarily needs treatment. Certainly this is likely to be true for ductal carcinoma in situ (DCIS), which consists of cancerous cells that have not yet invaded through the basement membrane of the ducts. Unfortunately, this is the predominant form of breast cancer that is detected by mammography.  Indeed, the authors even point out that their method didn’t allow them to disentangle the incidence of DCIS from that of invasive breast cancer, thanks to the way that the SEER database is setup. The problem, of course, is that we don’t know how to predict which cancers will progress and which cancers will not.

Finally, for all the confusion this study causes, there is one spot of good news, and that’s the observation that much of the decline in breast cancer mortality over the last 20 years—yes, contrary to what you might have heard, breast cancer mortality has actually been steadily decreasing—is likely due to improvements in treatment.

Finally, he reminds us that, for all its limitations, mammograms are not going anywhere anytime soon.

…right now reports of the death of mammography are very premature. To me, what is most important in breast cancer screening right now is to develop reliable predictive tests that tell us which mammographically detected breast cancers an be safely observed and which ones are likely to threaten women’s lives. We are currently at a point where imaging technology has outpaced our understanding of breast cancer biology, or, as Dr. Welch put it, “Our ability to detect things is far ahead of our wisdom of knowing what they really mean.” Until our understanding of biology catches up, the dilemma of overdiagnosis will continue to complicate decisions based on breast cancer screening.

Thanks, Orac. I always learn from reading your posts.

Inspirational – Morten Lauridsen’s Lux Aeterna

Morten Lauridsen’s amazingly beautiful Lux Aeterna. I first heard this choral music in a cathedral in Florence, and am thrilled to be singing it this weekend with The Collegiate Singers here in New York.

I’ve been singing The Lux for 5 days straight now and I swear, such a sense of incredible peace has invaded me. The only thing I can think is that it is this music – it is so calming, yet lush and expansive. (Thanks Elena for those adjectives…)

You can hear the entire piece on You Tube (there are three parts).

Remove Restrictions on Emergency Contraception

The Reproductive Health Technologies Project is sponsoring a petition to remove the current restrictions on emergency contraception and allow it to be placed on pharmacy shelves next to the condoms.

In December of 2011, the FDA was prepared to make emergency contraception accessible to consumers without restriction, based on more than a decade of medical research and policy debates. Instead, HHS Secretary Kathleen Sebelius overruled the FDA, putting politics ahead of women’s health. Her decision created unnecessary confusion for women and couples at a moment when clarity and timing matter most.

Despite Secretary Sebelius’ December 2011 decision, no evidence suggests that making emergency contraception accessible leads to risky behavior among teens. What it does do is give teens a second chance to prevent and unintended pregnancy so they can stay in school…

Emergency contraception is a safe, effective back-up method of birth control that can prevent pregnancy after unprotected sex or contraceptive failure. A woman is healthiest when she can decide the timing and spacing of her pregnancies. Let’s ensure that any woman who needs EC can get it safely and quickly.

Both the American College of Ob-Gyn and the American Academy of Pediatrics have released opinions supporting over the counter EC Access.

And as I’ve written before, emergency contraception is safer than Tylenol.

‘nuf said. Go sign the petition. (I did)

Understanding Mammogram Over-Diagnosis

This video from H. Gilbert Welsh, the author of the recent controversial NEJM paper on mammogram screening, should be required viewing for every woman and her doctor. (HT to Gary Schwitzer for bringing it to my attention.)

 

Bottom line – three decades of mammogram screening has had only a modest impact on the incidence of late stage breast cancer, and leads to over-diagnosis and over-treatment of early stage cancers in return. Declines in mortality are modest, and can be attributed in large part to advances in breast cancer treatment.

Overall, mammograms are thought to lower breast cancer mortality by about 15-20%. Which ain’t nothing. But it’s a lot less than most people think.

If you want to see what a highly effective cancer screening intervention looks like –

Let’s look at pap smears and cervical cancer screening – in this case in the UK, where a nationwide cervical cancer screening program was introduced in the late 80’s. Note the dramatic decline in the incidence of cervical cancer resulting from screening and subsequent treatment of pre-cancerous lesions-

With a concomittent large decline in cancer mortality that has not been disputed (note how the angle of the decline drops significantly in the late 80’s when screening is introduced) .

What is not shown in these graphs is the sharp increase in precancerous cervical disease that went along with the decline in invasive cancer and later stage disease – exactly what you’d expect from a highly effective cancer screening intervention. Pap smear screening works because cervical cancer has a relatively long precancerous phase during which screening and treatment can be done to prevent progression to cancer. (Colon cancer screening works the same way).

Mammograms are just not working as well as pap smears and colon cancer screening works. Either they don’t find the treatable early or pre-cancerous lesion in enough cases to make the kind of impact we were expecting, or more likely, not all so-called “early” breast cancers are destined to progress or cause death if diagnosed later or left untreated. This is supported by the fact that increases in the diagnosis and treatment of DCIS (Ductal carcinoma in situ) has not led to much of a decline in later stage breast cancers in the same way that treating cervical carcinoma in situ prevents invasive cervical cancer and cervical cancer deaths.

We are beginning to think that there are different types of breast cancers – those that are slower growing and less likely to metastasize and kill, and those that are aggressive from the get-go. Screening tends to pick up the former (hence the term “over-diagnosis”) and miss the latter, since they grow and spread so quickly.

This does NOT mean that no woman should get a screening mammogram.

It is saying that we need to have a more realistic understanding of what mammograms can and can’t do, and supports the recommendation that we make make decisions about mammogram screening that are based on that reality.

It also will hopefully help to dispel the prevailing myth that if every woman just got a mammogram every year, there would be no deaths from breast cancer.  Sadly, that is just not true.  Mammograms do prevent some deaths from breast cancer.  But not all of them. And the price we pay for preventing the deaths we do prevent is over-diagnosis and over-treatment of some women who may never have died from their cancer in the first place.

The problem, of course, is that at  present we have no way of knowing which women we are over-treating and which women we are saving.

Until we can do so, we must and will continue to offer screening mammograms.

When to start that screening, and how often to have it, is the question each woman must ask and decide with her doctor.  Hopefully, videos such as this one will help in making those screening decisions informed and reality-based.
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Recommended Reads

Tarragon-Cream Turkey Pot Pie

I awoke late today, feeling a bit melancholy. Eldest daughter left very early to go back to school, younger daughter is heading off with a friend to a museum, and the hubbub of the Thanksgiving holiday is over. As one who thrives on hubbub, I am a bit thrown by the quiet.  Although I had been counting on this free day to get quite a few things done, I find myself uninterested in doing anything, and since it is too cold for a bike ride, I instead waste the morning in front of the computer, allegedly handling email but in reality accomplishing nothing.

My husband, the math teacher, appears unfazed and is preparing math contest problems for his class. He brings a particular difficult one to me for help in solving, and though I remember little about geometry I do find his error – a simple math mistake. I decide that he too must be having trouble today as our little family once again rearranges itself from a quadrilateral to a triangle.

This realization reassures me somehow, and I am jolted back into activity. In short order, I shower, make the bed, eat breakfast, finish last week’s open encounters and lab result reviews online, write a few checks and finish a few odds and ends I’d been putting off doing. I then head out for a much needed mani-pedi, during which I start on my book club’s monthly selection (Age of Miracles, OMG you have to read it) and then come home to tackle dinner, which of course means the turkey leftovers.

Inspired by this recipe from Ina Garten, and remembering this delicious preparation for chicken breasts, I decide to make a pot pie using plenty of tarragon. This will also allow me to finish up that herb’s harvest before frost takes what’s left. (It did not survive last winter…)

Unfortunately, my younger daughter arrives home too hungry to wait for me to make the pies, so instead we compromise and serve half the filling over penne tonight (delicious), with the rest in small individual pies that cook while we eat dinner.  They finish baking just as we finish the dishes, and they are gorgeous. We’ll serve them tomorrow night, but of course I take a small taste – yep, this recipe is a keeper.

And so was this day.

Tarragon-Cream Turkey Pot Pie

The tarragon gives a light feel to what could otherwise be a heavy dish. (Much the same way adding lemon can lighten a dish). I made individual pies, but you can make one large pie if you prefer. If you don’t have time for a pie, make the filling and toss it with some penne pasta (pass the Parmesan when serving it).

  • 1 double recipe Pate Brisee
  • 2 tbsp butter
  • 1 tbsp olive oil
  • 3 large leeks, rinsed and into large dice
  • 3 large stalks celery, cut into large dice
  • 3 large carrots, peeled and cut into large dice
  • 10 ounces Crimini mushrooms,stemmed and cut into quarters
  • 2 cloves garlic, minced
  • 3-4 tbsp chopped fresh tarragon leaves
  • 1 tbsp fresh thyme leaves
  • 4-5 cups leftover turkey, shredded or cut into bite size pieces
  • 1 cup chicken broth
  • 1 cup cream or half and half
  • 1/2 cup white wine
  • salt and pepper to taste
  • Beurre manie  -1 tbsp flour mixed with 1 tbsp soft butter in a small bowl (optional)
  • Egg wash – 1 egg whisked with 1 tsp water

Prepare pastry and roll out half to line individual tart pans. Preheat oven to 375 degrees fahrenheit.

Heat olive oil and butter is a large skillet. Saute leeks, celery and carrots till they start to soften. Add mushrooms and cook till they just give off their liquid Add garlic and saute another minute. Add turkey, tarragon, thyme, chicken broth, cream and wine and heat to boiling, then turn down heat to low and thicken with flour-butter mixture (if necessary). Cool slightly and pour into tart pans. Roll out top pastry and cover tarts, crimping the edges to close the pastry. Cut three small slites in the top of each tart. Brush with an egg wash. Place on baking sheet and bake for 45-50 minutes, till crust is brown and sauce is bubbling.

Makes 8 individual or one large pie.