I found this little guy on the terrace in the parsley pot when I went out to snip some herbs for dinner this evening. Now I know why our parsley crop is so measly – it’s being eaten!
This black swallowtail (also known as a parsley worm) will be a gorgeous Monarch butterfly very soon if the birds don’t get him. I think I”ll leave him alone for now. The season is almost over, and he’s too pretty to squash.
Awhile back, I wrote about how a simple change in office workflow (and a smart office layout) allowed me to get back some of the face time with my patients that I had lost when we transitioned to an electronic medical record (EMR). As a result, I am happier, my patients are happier and I like to think I am providing better care.
Now, a new study shows that my instincts were right on – face time with patients is important. Researchers found that providers using an EMR detected and treated less depression in their patients than those still using paper, although the differences were only found in patients with three or more chronic conditions. The authors theorized that EMR using providers are spending more time looking at the computer screen than at their patients, and missing cues in facial expression and body language that in the past tipped them off to depression in their patients.
…EMRs have been observed to have a negative impact on psychosocial exchange, with screen gaze being inversely related to physician engagement in psychosocial questioning and emotional responsiveness. It is possible that the clinical work flows embedded in EMRs inadvertently encourage physicians to focus on these multiple physical problems and push depression treatment “off the radar screen” even after physicians diagnosed the condition…
…it has shown that physicians often find that EMR interfaces create additional work by forcing them to click through many screens and options as well as imposing tasks previously handled by others, especially when placing orders. Similar effects in primary care may take away significant visit time and reduce physician’s cognitive performance in terms of ability to provide comprehensive care. Such effects are also likely to be significantly greater during visits by patients with multiple chronic conditions than patients with few chronic conditions.
Even with my new work flow, I find that I still frequently have to consciously pull my eyes away from the screen and force myself to stop typing and look at my patients while they talk. This research study has me thinking that I meed to keep tweaking my work flows to see if I can improve face time even more than I already have.
Remember what I said once about great recipes being infectious? Well, here’s another one.
Looking for a good way to prepare two gorgeous yellow squash we picked up at the 79th St Greenmarket on Sunday, I came across a recipe for quick zucchini and almond saute on Deb Perelman’s blog Smitten Kitchen. And then the same recipe on Adam Robert’s blog The Amateur Gourmet. And then on Confessions of a Picky Eater. And then on about another million and a half other food and mommy blog sites, all inspired by Deb’s recipe.
Deb herself was inspired by Jimmy Bradley, the chef at The Red Cat – a restaurant I’d passed by on Tenth Ave in Chelsea, but have never thought to try. Of course now that I’ve made this recipe, the Red Cat is at the top of my list of must-eat places. Jimmy has been sharing his recipe for Quick Sauté of Zucchini with Toasted Almonds and Pecorino all over the internet, TV and radio since The Red Cat Cookbook came out in 2006. So if you google Jim’s name and zucchini, you’ll see a whole ‘nother spate of food bloggers who’ve made this dish.
Now, this recipe had mutated a bit from its source. While Bradley makes his preparation with 1/4 cup of oil and two separate fry pans, Deb uses only 2 tbsp of oil and makes it all in one pan, mentioning Bradley’s tent of pecorino as more of an afterthought. Hmm…easier to make and lower calories and fat. I knew which version I was making.
But wait – Mine would have yellow summer squash instead of zucchini. Another mutation!
Let’s see how far this one spreads….
[amd-recipeseo-recipe:4]
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How to Julienne a zucchini – great video comparing a knife to mandoline. Wish I’d found it before I cut up my squash!
The United States Preventive Services Task Force has recommended against routine screening with ultrasounds or blood tests for ovarian cancer in asymptomatic women at average risk for the disease.
The reason is simple – these tests are not effective screening.
“There is no existing method of screening for ovarian cancer that is effective in reducing deaths,” Dr. Virginia Moyer, the chairwoman of the expert panel, said in a statement from the group, the United States Preventive Services Task Force. “In fact, a high percentage of women who undergo screening experience false-positive test results and consequently may be subjected to unnecessary harms, such as major surgery.”Yes, there is ultrasound and CA125. But doing these tests in healthy women without symptoms and at average risk causes more problems than it prevents, and most importantly, it does not prevent deaths from ovarian cancer.
Screening is recommended for women who carry genetic mutations that increase their risk of ovarian cancer (such as BRCA or MLH1 mutations), although its impact is still not entirely certain even in this group. More effective in this group is prevention by prophylactically removing the ovaries and fallopian tubes, which will prevent 95% of the ovarian cancers that occur in these women.
While ultrasound has no role in routine screening for ovarian cancer, it remains an important diagnostic tool when women present with symptoms that could be signs of ovarian cancer – bloating, abdominal pain, decreased appetite or early fullness after eating and new onset urgency and frequency of urination not due to other causes such as a UTI. Of course, almost all of the time these symptoms will not be due to ovarian cancer, but it’s important to rule it out.
We May Not Have Effective Screening, But We Do Have Effective Prevention for Ovarian Cancer
What does prevent ovarian cancer is birth control pills. Women who use the pill for as little as 1-2 years will see a 22% reduction in risk, and in long term users get a 60% reduction in risk. Although protection wanes with time, it persists as long as 30 years after stopping the pill. It is estimated that birth control pills have prevented over 100,000 deaths from ovarian cancer to date. (Not to mention pregnancy prevention and other health benefits.)
Users of Depo-Provera may get a similar reduction in risk as pill users do. In addition, tubal ligation may also reduce ovarian cancer risks. Studies are underway in high risk women to see if removal of all or part of the fallopian tube is effective as removal of the ovaries.
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More Posts on Ovarian Cancer from The Blog that Ate Manhattan
There’s a big discussion going on in the health tech community about a controversial keynote speech given by Vinod Khosla at the Health Innovation Summit (HIS), in which he stated that 80% of what doctors do could be replaced by machines.
If you’re a doc like me who has no idea who the heck Vinod Khosisa is (he’s a venture capitalist and co-founder of Sun Microsysstems), why he’d be a keynote speaker at a healthcare event and what the heck HIS is, well, that’s the point of this post.
You see, there are a whole lot of folks like Khosia out there – investors, entrepreneurs, tech types – who are attempting to redefine healthcare according to their own personal vision. Where we see a healthcare system in crisis, they see opportunity – just another problem with a technological solution. Computer-driven algorithms are the answer to mis-diagnosis and medical error, IPhone apps can replace physician visits, video connectivity can increase access.
Where we see illness and distress, they see a market.
And what business folks like to call disruption in the marketplace. Think about what happened to downtown small town USA after the first shopping mall opened. Or what happened to movie houses when Netflix started offering DVD rentals online. Or where all the independent bookstores went when the first Borders opened up, and what happened to Borders when the Kindle hit the market.
Out with the old, in with the new.
If Khosla is right, the we docs in our offices and hospitals are the old downtown department stores, the bookstores and the bricks and mortar businesses in an online revolution.
We’re replaceable. At least most of us.
Is Khosla right?
Maybe.
The therapeutic relationship between a doctor and a patient can never be replicated by an IPhone app. Not when so many of my patients leave my office on a daily basis telling me how much better they feel just having spoken to me. It’s a powerful and sacred relationship that is irreplaceable.
These days, however, almost all of my patients have googled their symptoms, and many have done a over the counter diagnostic test or treatment before coming in to see me. I’ll never see the ones who got their questions answered online or their symptoms cured by that over the counter med – I see what’s left after self-diagnosis and self-treatment has failed, or google told them to see me.
That’s disruption, isn’t it?
One day very soon, women will be able to screen themselves for cervical cancer and std’s using a self-administered vaginal swab. No need to see me unless the test is abnormal, or there are symptoms.
Disruption.
Of course, computer driven diagnostic algorithms, apps and programs can create a whole new set of problems in over-diagnosis, since “there’s nothing seriously wrong with you” is rarely an output. In my office, that’s a very frequent clinical assessment. Functional ovarian pain. The occasional errant menstrual cycle or missed period. Anxiety. Stress. Depression. Lack of sleep. Over-eating, over-drinking, over-medicating. What computer is going to pick that up?
Not to mention trauma care, surgery, childbirth, respiratory distress and any one of thousands of health emergencies that you can’t treat with an IPad. I don’t see any of that work going away for docs anytime soon, do you? Some of it, of course, is being shared with trained non-physicians, and even robots. But docs are still an indispensable part of the healthcare mix.
So while the mix is changing, we docs are still in it. And I don’t see that changing. At least for here and for now. But the future?
I don’t know.
Docs need to be part of the digital revolution
I do know that if this is the new revolution in healthcare, we docs better get in on it.
Take the EMR as an example of what happens when docs let non-docs innovate in healthcare without significant physician input. We become typists, not physicians. Clerical work that used to be done by lower paid staff – entering lab and radiology orders – becomes ours to do. We spend the majority of a patient visit looking at a computer screen and not the patient. Retrieving relevant clinical information is like searching for a needle in the haystack of required fields of entry, most of which are not necessary to provide care.
Indeed, we have not yet shown definitively that EMR’s improve outcomes.
And yet we’re all using them, aren’t we?
If we are not part of the digital revolution and leave it to the venture capitalists and entrepreneurs, they will develop products that may sell, but if they don’t improve outcomes, all that will have been accomplished is a disruption in a marketplace.
Wouldn’t it be so much better if we could disrupt disease?
The real opportunity in Healthcare Innovation
There are millions upon millions of folks – some in American, but most in the undeveloped world – who have never had, and will never have the opportunity for a patient-physician therapeutic relationship such as that I’ve described above. They have no one to call when Google tells them to “talk to your doctor”.
But the overwhelming majority of the do have cell phones. Amazing, really. We can’t get indoor plumbing modern contraception or malaria tents to those in need, but 80% of folks in the developing word have cellphones. If that’s not an opportunity and a potential market for healthcare innovation, then nothing is. If we can get any healthcare into the hands of these folks, even if it’s healthcare delivered by a mobile app, we have the potential to improve their lives.
Now, imagine that we docs were able to free ourselves from the 80% of our work that can be replaced by technology, and then redistributed ourselves (virtually and personally) across the globe where we were truly needed, so that we could provide needed healthcare to the entire planet?
Now that’s disprution.
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Recommended reading
Poached fruit is one of my favorite desserts, especially in September when the cooler evenings beckon us to eat outdoors on picnic tables covered in cotton tablecloths, a sweater at hand for when the sun sets. And that moment, when the crickets start and the fireflies come out, is the perfect time to ladle warm, sweet fruit atop cold vanilla ice cream, top it with a sprig of fresh mint and bring it out to the porch. If you haven’t finished that bottle of wine you opened at dinner, now is the time.
[amd-recipeseo-recipe:2]
This is a new favorite quick evening meal in our household, straight from the pages of Cooking Light Magazine. All we added were a few grape tomatoes.
I love having eggs for dinner – there is something so homey about it. I also like that this meal uses ingredients we usually have in stock – all we need to pick up at the store on the way home is fresh cilantro and maybe a lime – though if we have a lemon at home I’d use it instead. If you don’t keep Panko around the house (we usually have a bag in the freezer), use some old bread to make your own breadcrumbs instead.
A Stanford University meta-analysis comparing the health effects of organic to non-organic food has concluded that organic meat and produce, while not necessarily more nutritious than conventionally raised food, does harbor less antibiotic resistant bacteria and less pesticide residue. Pesticide levels are also lower in children consuming food from organic vs conventional sources.
[The researchers reviewed]7 studies in humans and 223 studies of nutrient and contaminant levels in foods met inclusion criteria. Only 3 of the human studies examined clinical outcomes, finding no significant differences between populations by food type for allergic outcomes (eczema, wheeze, atopic sensitization) or symptomatic Campylobacter infection.
Two studies reported significantly lower urinary pesticide levels among children consuming organic versus conventional diets, but studies of biomarker and nutrient levels in serum, urine, breast milk, and semen in adults did not identify clinically meaningful differences.
All estimates of differences in nutrient and contaminant levels in foods were highly heterogeneous except for the estimate for phosphorus; phosphorus levels were significantly higher than in conventional produce, although this difference is not clinically significant.
The risk for contamination with detectable pesticide residues was lower among organic than conventional produce (risk difference, 30% [CI, −37% to −23%]), but differences in risk for exceeding maximum allowed limits were small.
Escherichia coli contamination risk did not differ between organic and conventional produce. Bacterial contamination of retail chicken and pork was common but unrelated to farming method. However, the risk for isolating bacteria resistant to 3 or more antibiotics was higher in conventional than in organic chicken and pork (risk difference, 33% [CI, 21% to 45%].]
The researchers also found less fungal toxin contamination in organics and higher levels of Omega 3 fatty acids in organic dairy.
This is all important information for consumers who want to lessen their family’s exposure to pesticides, some of which can be endocrine disruptors and have been linked to cancer. It also supports organic claims as to the superior fatty acid content of milk and poultry.
Poorly Spun
And yet, here’s the way Stanford themselves pitched their research to the media –
Little evidence of health benefits from organic foods, Stanford study finds
BY MICHELLE BRANDTCrystal Smith-Spangler and her colleagues reviewed many of the studies comparing organic and conventionally grown food, and found little evidence that organic foods are more nutritious.
You’re in the supermarket eyeing a basket of sweet, juicy plums. You reach for the conventionally grown stone fruit, then decide to spring the extra $1/pound for its organic cousin. You figure you’ve just made the healthier decision by choosing the organic product — but new findings from Stanford University cast some doubt on your thinking.
“There isn’t much difference between organic and conventional foods, if you’re an adult and making a decision based solely on your health,” said Dena Bravata, MD, MS, the senior author of a paper comparing the nutrition of organic and non-organic foods, published in the Sept. 4 issue of Annals of Internal Medicine.
Huh? Exposure to pesticides and antibiotic resistant bacteria is not a factor to be considered in making buying choices based on your health? Omega 3 fatty acids are not important? Says who?
The researchers pointed out that they found only 17 human studies, too little to really base any long term recommendations, hence the “little evidence”. But there is “little evidence” because a hypothesis has been disputed, and “little evidence” because the volume of data is too small on which to base conclusions. The latter is clearly the case here, but the headline makes it appear to be the former.
The authors also point out that despite differences in pesticide exposure, most exposure, even in conventionally grown produce, was below government limits. But that’s not the point, is it? Organic proponents think government limits are too high in the first place, so this is not reassuring to them, or informative to the public.
And note also that Bravata was careful to say “If you’re an adult” – I would assume that means if you’re feeding a child, you may want to think differently.
My conclusions on the study
I’d say this study pretty much supports the claims that organic producers are making when it comes to the issues most important to consumers who choose organic food sources.
The media is all over this one
Headlines range from ” Stanford Scientists Cast Doubt on Advantages of Organic Meat and Produce” (NY Times) to” Organic Food Has Little Health Impact” (Fox News ) and “Organic Food is not healther than conventional produce” (Huff Post). Reuters actually had a more accurate headline “Organic food no more nutritious than conventionally non-organic” , which still is misleading in that it ignores the pesticide data, which is actually the reason most folks prefer organic.
I say ignore the headlines and read the study yourself. See what conclusions you come to, and buy accordingly.
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Essential Reading
A big shout out to Tara at Tea & Cookies for this wonderful recipe for making hash browns using a waffle iron. It’s really a quite healthy and low-fat preparation. I’m not posting a recipe here – Tara’s recipe is complete with fabulous prep photos. My only addition was a generous grating of black pepper.
The only downside of this recipe is the length of time it takes to cook – 20 minutes in my two-waffle iron. If you need to make more than two waffles, you can hold the finished waffles in the oven at 200 degrees fahrenheit without losing crispness.
My husband, the king of hash browns, wanted me to try adding onion – so I added some grated and drained onion. The taste was great, but they were too wet and burnt a bit. I think I’ll stick with Tara’s simpler version.
If you want prefer traditional hash browns, here’s the best recipe I know.
One of the most beautiful spots in America is in Red Rock, Pennsylvania – the middle of nowhere, really and about two and a half hours equidistant from New York City, Philadelphia and Harrisburg. It’s called Rickett’s Glen State Park, and it’s home to one of the most fabulous hikes I’ve ever taken, the Falls Trail.
This 7.2 mile hike through old timber forest ,
takes you alongside Kitchen Creek
as it splits and makes its 1,000 foot descent down the Allegheney Front.
Along the way, you’ll cross over wooden footbridges,
and climb and descend rock steps
that take you alongside over 20 waterfalls,
the highest of which, Ganoga Falls, is 94 feet tall.
Wear sturdy shoes and a carry a good walking stick, pack a lunch and, if it’s warm and you are brave enough to confront the chilly waters, wear a bathing suit under your hiking shorts.
Take your time – this is too pretty a hike to rush (We took about 4 and a half hours, including stops for lunch and two swims) . Please be careful, especially when walking downhill. But don’t let the climbing dissuade you – the first, last and mid-portions are flat
and there are plenty of places to rest.
If you’re in halfway decent shape you’ll be fine, if not a bit sore the day afterwards. Well worth it, I say. We’ll be back again when the leaves change. I can’t wait to see this place in the fall.
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More on Ricketts Glen from around the web
It’s a question I found myself asking after reading that a diet rich in the natural plant compound phenethyl isothiocyanate (PEITC) has been shown to prevent the development of mammary tumors in mice. PEITC is a compound found in watercress and in cruciferous vegetables such as broccoli and cauliflower.
The researchers found that administering PEITC for 29 weeks was linked with a 56.3% reduction in mammary carcinoma lesions greater than 2mm. “Although PEITC administration does not confer complete protection against mammary carcinogenesis, mice placed on the PEITC-supplemented diet, compared with mice placed on the control diet, clearly exhibited suppression of carcinoma progression,” the authors write. PEITC was also well-tolerated.
Although studies on PEITC in mice are quite promising, proving that PEITC works in humans is not so easy. Dietary studies in humans are exceedingly difficult to perform, and studies of PEITC-rich foods and cancer rates have had mixed results to date. Still, we do know that people who eat a diet rich in fruits and vegetables have lower rates of certain cancers, as well as less heart disease, hypertension and diabetes.
Those are enough reasons to feel good about eating your broccoli. Here’s my new favorite recipe for eating mine.
ROASTED BROCCOLI
Although there are many wonderful roast broccoli recipes out there (see links below), the simplicity of this preparation makes this it a versatile accompaniment to almost any meal.
Prep Time: 5 minutes
Cook time: 25 minutes
Yield: 4 servings
Ingredients:
– 1 head broccoli
– Extra virgin olive oil
– Sea salt & fresh ground pepper to taste
Instructions:
Preheat the oven to 450 degrees Fahrenheit. Cut the broccoli into large florets. Cut off the end of the stalk and discard, then slice the remaining center stalk into 1/8 inch thick rounds. Spread the broccoli out in a single layer on a large baking sheet. Brush with olive oil and season with salt and pepper. Roast 15 mins or so, till just tender and the edges are nicely browned, stopping halfway through to turn the broccoli and re-brush as needed with olive oil.
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NCI info on cruciferous vegetables and Cancer
More great broccoli recipes
On the heels on NY State’s Breast Density Notification Law, which mandates that women with dense breasts be told they may be at increased risk for breast cancer, comes the reassuring news that having increased breast density does NOT increase the risks of dying from breast cancer.
In order to determine if higher mammographic breast density is linked to a reduced survival in breast cancer patients, Gretchen L. Gierach, Ph.D., M.P.H., of the Division of Cancer Epidemiology and Genetics (DCEG) at the National Cancer Institute in Maryland, and colleagues looked at data from the U.S. Breast Cancer Surveillance Consortium and examined 9,232 women who were diagnosed with primary invasive breast carcinoma between 1996–2005 with an average follow-up of 6.6 years. The researchers studied the relationships between mammographic breast density and risk of death from breast cancer and all causes. Mammographic density was measured using the Breast Imaging Reporting and Data System (BI-RADS) density classification.
The researchers found that density does not influence the risk of death once the disease has developed. They write, “It is reassuring that elevated breast density, a prevalent and strong breast cancer risk factor, was not associated with risk of breast cancer death or death from any cause in this large, prospective study.”
Studies such as these are point out that the most important factor in breast cancer survival is the behavior of the the tumor itself, and not necessarily the risk factors that led to development of cancer in the first place. The analogy I like to use is that of traffic density and accident mortality. The chance of your being in a car accident is of course increased as population and number of drivers, automobiles and passengers in them increases. But your chance of dying in an individual car accident is related more to the circumstances of that accident – the drivers involved, the speed, the road conditions that day, etc – than to the fact that the accident occurred.
One more argument against mandatory breast density notification laws
Presuming that the woman in this study had their mammograms done long before any state passed a breast density law, this study further begs the question as to what benefit these laws will have for women, especially those under age 50, most of whom have dense breasts. (See my previous post on why these laws are misguided.)
At this point, breast density laws are simply legislation based on uncertain science advocated for by women desperate to eradicate breast cancer deaths and passed by legislators who refuse to accept the uncertain state of medical science.
In my opinion, it would be better to focus our legislative efforts on funding research in to the possible environmental causes of breast cancer, and on reducing the levels of known carcinogens in our environment.
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CBS News does a great job reporting on this issue
The winner of this giveaway random drawing is Sarina –
SarinaAugust 28, 2012 | 3:26 pm Edit
LOVE! I’ll where them in our monthly baby bump shots!
Aren’t these the cutest thing? I saw them in a stationary store in Salzburg last month and just had to buy them. Of course, now that I’m home I’m not sure what to do with them. I could give them to a certain someone I know who is pregnant, but truth be told, I’m not sure she’d wear them.
Which got me to wondering just who might wear a pregnancy button, and under what curcumstances. To work? A party? On the street? At home?
And where would one wear it? On one’s belly? Or a lapel? Would you wear them?
Just post a comment giving us your thoughts on wearing pregnancy buttons and you’ll be automatically entered to win the buttons for yourself or to give to someone you know who is pregnant. One entry per person. Contest ends and winner will be announced on September 3 – that’s Labor Day, of course.
MOST RECENT POST ON THIS ISSUE Dense Breasts on Mammogram. No need to be Afraid.
Once again, legislators are meddling into healthcare. This time, it’s in my own home state, where Governor Cuomo has just signed a bill requiring radiologists to notify women when their normal mammogram also shows that they have dense breasts. In such cases, the following text must be included in the lay summary mammogram report given to the patient –
“Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer.
This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.”
New York is the fifth state to pass a mandatory breast density notification law. As of this writing, Connecticut, Virginia, California and Texas have similar laws.
What is Breast Density ?
Breast density is a subjective radiologic assessment of how well x-rays pass through the breast tissue. It is a surrogate for how much of the breast is composed of glandular tissue and how much is fat. The radiologist reading the mammogram classifies the breast composition as one of the following –
For the purposes of the law, dense breasts are defined as those that are heterogeneously dense or extremely dense.
Mammographically dense breasts are extremely common, especially in younger women. According to a recent report of mammograms here in New York City, 74% of women in their 40s, 57% of women in their 50’s, 44% of women in their 60’s and 36% of women in their 70’s had dense breasts.
What We Know (and Don’t Know) About Breast Density
Increased breast density can be a risk factor for breast cancer .
The mechanism is unknown, but it may be that breast density is just the end result of other factors that increase breast cell proliferation and activity – factors like genetics and postmenopausal hormone use.
How much of a risk? Well, it depends on what study you read and who you compare to whom. If you compare the two extremes of breast density in older women, those with extremely dense breasts have a three to five-fold higher cancer risk than those with mostly fatty breast. The risk is lower than that in those in the middle category of breast density and in younger women, though not well-defined.
The truth is, we really have no way to translate individual breast density into individual risk. Researchers are trying to see if breast density can be incorporated into current risks assessments such as the Gail Model, but at this point, breast density has not been shown to add much more than we already know about a woman’s risk from using these models.
Dense breasts can obscure a cancer on mammogram.
This makes mammogram less reliable in women with dense breasts. Digital mammograms may be better at finding breast cancers in women with dense breasts who are also peri-menopausal or < age 50, but it is not known if this translates into better outcomes.
Additional testing with ultrasound and MRI can find cancers that mammograms miss in women with dense breasts. Unfortunately, breast ultrasound and MRI screening tests are less specific than mammograms – three times as many biopsies will be done, most of which will not be cancer.
We do not know if additional screening beyond mammograms saves lives.
It might seem to makes sense that it would, but there are no randomized trials to show this. For now, this additional screening is only recommended in women at highest risk for breast cancer based on other factors such as genetic, family and personal health history.
Why the Breast Density Law is Misguided
Our legislators have women’s best interests at heart, but unfortunately, when it comes to the practice of medicine, they really don’t know what they are doing. Allow me to explain…
1.Most women under age 60 have dense breasts.
Three quarters of New York women in their 40’s, all of whom have just had a normal mammogram, will now be told that they may be at increased risk for breast cancer.
2. Breast density measurement is subjective. Different radiologists may give the same mammogram different ratings. Use of computerized density measurement could alleviate inter-observer variability, but there is not yet a standardized computer rating system.
3. Breast density can vary across a woman’s menstrual cycle and over her own lifetime. The same women being scanned at a different time of month or at a later year can land into a higher or lower breast density category, and may or may not get that letter above. Recent research suggests that a single breast density reading may not be the best way to predict breast cancer risk, and that the risk may be confined to those women whose breast density does not decrease with age.
4. Sonogram and/or MRI for breast cancer screening is currently not recommended based on breast density alone. Additional screening beyond mammography is only used in women at highest risk for breast cancer – those with cancer in a first degree relative with a high risk gene mutation, a family history suggesting one of these mutations, a Gail model or other combined lifetime breast cancer risk assessment >25% or a history of chest irradiation. Even in this group, declines in morality with the additional screening have not yet been shown, and the false positive rate of this additional testing is extremely high – only 20% of abnormals are cancer when biopsied.
There are no recommendations to use sonogram and MRI in otherwise low risk women, and none that have shown that using it based on breast density alone saves lives.
5. Additional screening adds significant costs to breast cancer screening. For some women, this additional cost may not be covered by insurance. While Connecticut has passed a law mandating that insurers cover additional sonograms, New York State has not.
6. The law is a medico-legal nightmare. The legislators are creating a medical standard where there is none. That however, has never stopped the lawyers.
I would expect a lot more business for radiologists doing defensive breast ultrasounds ordered by referring docs who don’t want to get sued for a missed diagnosis by a woman with dense breasts. After the first breast density law passed in Connecticut, the use of ultrasound in that state skyrocketed. (The American College of Radiology, by the way, urges caution on breast density legislation.)
I would also expect a lot more lawsuits for missed diagnosis aimed at the referring physicians whenever dense breasts are noted on a mammogram, even if that woman had no other risks factors for breast cancer.
7. The EMR Makes This Law Unnecessary. As EMR use expands, women will be able to read their actual radiology report online. Those who want to know their density will, and the rest will not be unnecessarily alarmed.
8. The law violates the free speech of physicians. This regulation did not originate from within the medical community or the department of health. It is a lay attempt to push screening beyond what the evidence supports at this point in time, and to set a medical standard (ultrasound for every woman with dense breasts) that does not exist.
At This Point, What Can be Done?
Short of radiologists filing a lawsuit claiming free speech violation ? (Not a bad idea I think…)
We have 180 days before the law takes effect. In that interval, I would recommend that the New York State Health department come up with some educational materials on breast density that informs rather than frightens women. They could include information about breast cancer, mammograms in general, their limitations, benefits and harms. And tell women what to do and where to go if they feel a lump or have a breast symptom. This additional material can be included with the report so that women actually get the information they need about breast cancer screening, rather than an unexpected scare when what they thought they had just gotten was a normal mammogram.
Hmmm, that’s actually not a bad idea…If someone wants to pass a law that Department of Health written breast cancer screening info be given out at the time of Mammography, I’d get behind it in a second.
But telling the majority of women in their 40’s who have just had a normal mammogram that they may be at increased risk for breast cancer? That’s just wrong.
About 15% of women with ovarian cancer are found to carry a germline mutation in the BRCA gene. That’s the gene also associated with an increased risk for breast cancer in women, prostate cancers in men and gastrointestinal cancers and melanoma in both men and women.
Typically, the risks for carrying a BCRA mutation are predicted based on personal and family history of BRCA-related cancers.
Now, data from Canadian researchers suggests that, among women with ovarian cancer, the tumor type itself – not family and personal history – is most predictive of BRCA risk.
In their study of 131 women with ovarian cancer, 25% of those with high-grade serous ovarian cancers had a BRCA mutation. In contrast, none of the women with other tumor types carried the mutant genes. Had they instead referred these same patients for standard-of-care genetic counseling and screening, a significant number of BRCA carriers would have gone undetected – 35% if the counselor was their doctor and 20% if they had seen a trained genetic counselor.
While their data is similar to other studies in terms of the percentage of serous cancers associate with the BRCA gene, none to date has shown such a striking difference between tumor type and BRCA status. In this regard, it’s important to note that the researchers used the latest scientific methods for determining tumor type, basing it not just on morphology (what a tumor looks like), but on special biochemical tests (sort of like fingerprints).
The authors are recommending routine BCRA screening in all women with high grade serous ovarian cancer, regardless of their family history.
In view of the strong association and high incidence (25%) of underlying BRCA1 and BRCA2 mutations in women with high-grade serous ovarian (pelvic) carcinoma, genetic assessment for consideration of BRCA1 and BRCA2 germline testing should be offered to all women diagnosed with this histologic subtype of ovarian cancer regardless of age or family history.
This makes sense to me.
Family history is often incomplete or erroneous. But knowing about BRCA status is important for both ovarian cancer patients and their families, who can use the information to tailor screening and preventive strategies to reduce their risk and allow for early detection and treatment of BRCA-related cancers.
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