Screening for Ovarian Cancer Based on Symptoms – Not Good Enough

Thanks to Toni Brayer for pointing out this new study on ovarian cancer symptoms published in the Journal of the National Cancer Institute.

This study confirms previous studies which found that ovarian cancer, long thought to be a silent disease in its early stages, does indeed have symptoms. The problem is that those symptoms – bloating, urinary frequency, pelvic pain, early satiety – are common, non-specific and, according to this new study, 99% of the time not due to an underlying ovarian cancer.

That’s good news, of course, for women with these symptoms. But bad news for those hoping for a means of early detection for ovarian cancer, since early symptom recognition is neither sensitive nor specific enough to be useful as a screening test on a population basis.

This is extremely important for women to understand. Each new screening test gets over-hyped and sets women up with unrealistic expectations about just what it is we docs can do to diagnose this disease. (The latest hope comes from a study that found elevated serum markers in women with ovarian cancer up to three years before their cancer was diagnosed. Unfortunately, the test were not useful in discriminating normals from abnormals until shortly before diagnosis.)
I don’t know if the results of this new symptom screening study will lead to changes in the current recommendations for ovarian cancer screening, so for now I will just reiterate them here –
If you have any of the following symptoms almost daily for more than a few week and these symptoms represent a change from normal for you, see your doctor, preferably a gynecologist.

  • Bloating
  • Pelvic or abdominal pain
  • Urinary urgency or frequency
  • Difficulty eating or feeling full quickly

Prompt medical evaluation may lead to detection at the earliest possible stage of the disease. Remember, though, that these symptoms are almost always caused by something other than ovarian cancer.


Wouldn’t it be great if we had a pill to prevent ovarian cancer?
Wait a minute – we already do! It’s call the Birth Control Pill. According to the National Cancer Institute, use of the pill for even as little as a year lowers ovarian cancer risk by 10-12%, and there is a 50% risk reduction after 5 years of use. Other studies show even higher risk reduction with longer term use.
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Those ovarian cancer awareness wristbands up there are sold to raise funds for the Lynne Cohen Ovarian Cancer Research Foundation. The Susan Komen Foundation sells them too. The Ovarian Cancer Research Fund has a whole store!

More info on ovarian cancer screening from The National Cancer Institute.

Healing Through Multiple Sclerosis

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Artist Cathy Aten talks about how dealing with progressive MS has led her to a remakable place.

My whole process of being an artist has been a 30 year process of editing – What all can you take away and still have the essence of a thing? So, slowly my life is being edited down in the same way that my my art has become edited down – into exactly what is necessary and nothing more.
And you know…What I need is a lot different than what I ever thought I needed. I like this person I’m becoming.

Inspirational.
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Thanks to Wheelchair Kamikaze for highlighting this video, and to Linda and Marie for pointing me to WK.

Is Healthcare ready for the IPad?

First off, I need to address those who think they’re being brilliantly funny comparing Apple’s new product name to a feminine hygiene product – making comments like “Does it come with wings?” and “It’s light and easy to use, but can you swim with it?” (these are the cleaner comments I’ve seen), or calling for the next generation ITampon.

Since when did the word “Pad” become unusable in public discourse? And where were these folks when IBM came out with their Think Pad? It’s stupid, 12-year old funny and just plain dumb. Grow up, ladies and gents.

Now, on to more serious matters.

Is the IPad, as some are suggesting, the next big thing in Medicine? Dana Blakenhorn at ZDNet thinks so, calling medicine the IPad’s “Sweet Spot”-

It’s what your doctor has been dreaming of ever ince the PC revolution began. Imagine this in a flip-up case, in every examination room at your clinic. The nurse sets up the chart, the doctor walks in with a stylus and examines you, and when he’s done the chart goes into the file and the prescription is waiting at the desk for you, printed clearly, along with your Coordination of Care Record. Hand the nurse your credit card and you’re off.

First of all, Dana, that script ain’t waiting at the front desk – it’s already in the pharmacist’s inbox. And my nurse isn’t the one swiping the credit card – my secretary is. But, more importantly, is Dana right?

Is the IPad what I’ve been dreaming of?

Let’s see – I already run my EMR on my PC at work and my Macbook at home, where I can multitask to my heart’s content, and don’t have to re-login to my EMR every time I move back and forth from that app to, say, my calendar, the web or my e-mail. Do I really want a device that does not multitask? Probably not.

You’re thinking it’s the apps, right? Lots of separate cool apps, all of which do really neat things like let me read EKGs or keep lists of patients or look up drug interactions. None of which talk or import data to one another and all of which I need to move back and forth between. Those apps?

Well, let’s see…My EMR looks up pharmacies and drug interactions, lets me access Up-to-Date from within my patient’s record, pulls in lab results from 3 different laboratory vendors and radiology reports from any of our offices and allows my patient to access these herself online. If she’s admitted to the hospital, I can access that chart through a different app, and the discharge summary and op notes make it into my office EMR. That’s one hell of an app, I’d say. Can’t think of too much more I need.

As for games and videos, I guess there’s always lunchtime, but I generally use that time to return phone calls, so…nope.

But wait – What if the IPad were to let me take a photo of say, a skin lesion, and plop it right into my patient’s chart – how cool would that be? Or I could Skype a patient and provide real time care over the internet – now we’re on the 21st Century! Oops, I forgot. No camera on the Ipad…

Maybe it’s the AT&T 3G network you’re thinking about. The one that drops my IPhone calls at least half the time? That 3G network? Not to mention I can’t access it anyway from my office, where the hospital’s concrete walls render even the best of cellphones powerless.

Ok, forget 3G. Maybe the IT guys at work will put in a router for me. That would be nice. Then, instead of being tied to my desk, I could go from room to room with my Ipad. But of course, I’ll need a way to keep the device clean. After all, Staph Aureus is ubiquitous, and has been found on hospital keyboards. Unfortunately, I don’t think I can use any of the current cleaners I have on the Ipad. That’s a problem.

The Real Question

It seems to me that the real question is not “Is Healthcare ready for the Ipad” but “Is the Ipad ready for Healthcare?” And the answer, sadly, is not just yet.

I’ll just have to keep on dreaming…
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More on the Ipad and Healthcare from around the Web
  • Dr Anonymous gives his thoughts on the Ipad – It’s the software, stupid.
  • John Halemka weighs in with some thoughtful questions about the Ipad’s suitability for patient care, but concludes it is “definitely worth a pilot”.
  • MobiHealth News takes the pulse of the Healthcare industry on the Ipad – Bottom line – not just yet.
  • IMedicalApps shows one place in healthcare where the Ipad shines – Anatomy Imaging
  • Brandon Glenn at Medcity does a great job summarizing the Ipad’s limitations
  • Chris Paton at the Health Informatics Forum likes the Ipad for docs – the comments from software developers are well worth a read if you want to see what the future for the Ipad may hold
  • Joseph Kim at Kevin, MD has 10 ways to use the IPad in your practice (none of which includes an EMR) 
  • Steve Woodruff , writing at Kevin Md, thinks the IPad will be a game changer in Healthcare. The operative word, in my opinion, is “will”.
  • Mike Kirkwood thinks a few EMR vendors, most notable EPIC (the one I use) are poised to enter the Iphone/IPad world. Now that would be very nice….

Working Class Foodie’s Apple Cake

I’ve been enjoying watching Working Class Foodie, a Web Show on Hungry Nation that features Rebecca and Max, two siblings with “a love of cooking and eating” who create simple meals using seasonal, local ingredients for under $8 a serving.

Their traditional apple cake recipe is a perfect example of simply delicious food. It’s your basic Jewish Apple Cake made from a recipe Rebecca and Max got from their aunt Tracy, who prefaced her recipe with these words to her niece and nephew – “Don’t mess it up!”

This recipe differs from others apple cake recipes I’ve seen in several ways – First the ratio of sugar to flour is almost 1:1. Other recipes I’ve seen have about a 2:3 proportion, making this cake considerably on the sweeter side. Perhaps to balance out the sugar, there’s a heck of a lot of cinnamon – 2 tbsp to be exact, compared to 2 tsp in most other traditional apple cake recipes. (Not to worry, it doesn’t overpower.) In many ways, the batter reminded me of the Commissary Carrot Cake (one of my fave cakes of all time – I’ll make and post it for you someday), and indeed when I checked that recipe, the proportions of eggs, flour, sugar and oil were almost identical.
The recipe gives the option of of using either white or brown sugar – I decided to go half and half with each. It also offers the choice of apple chunks or layered slices – I went with the chunks, since that’s how Rebecca does it in her video. I also followed more of a standard approach to combining the ingredients, mixing the dry ingredients in one bowl and the wet in another, then combining them, as opposed to Rebecca’s dump it all in at once approach. It’s just the way I learned to make oil-based cakes.Mr TBTAM absolutely loved this cake, as did my daughter and her friends. It was moist and flavorful, with a delightfully crispy crust. The cake did fall just a tad away from the crust as it cooled, but the dusting of confectioners sugar hid the unevenness of the top that resulted. The apple chunks were like little pieces of love embedded in sweetness. I have to admit, the cake was a bit sweet for my taste and I enjoyed the more natural sweetness of the apples in contrast to the sugariness of the cake.

I’d like to try this cake with some whole wheat flour substituting for some of the white flour and with a bit less sugar. I’ll bet the whole wheat would play off the apples really well. I think I’ll try it using one of those 2:3 ratio recipes, leave the skins on the apples, slice them paper thin and layer them. There’s a nice Polish Apple Cake recipe in Marlena Spieler’s book Jewish Cooking that I’ve been wanting to try that fits that bill pretty well.
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Rebecca and Max make their Aunt Tracy’s Apple Cake.

Medblog Award Finalists Announced

Wow. I never thought I’d make it to the finals of the Medblog Awards. And yet, there I am, nominated for best medical blog. I’m honored. Thanks to those who nominated me and to the judges for selecting me for the finals.

Voting starts today over at Medgadget. I encourage you to peruse the blogs nominated in all 7 categories – there are some wonderful sites worth adding to your blogroll. Then, cast your vote for your faves, sit back and watch the returns. It may not be as exciting as Massachusetts, but it’ll be fun!

I Can Has Grand Rounds

This week’s Grand Rounds is the The LOL edition at Emergiblog!

My particular faves

Inspiring – a post by Dr Rob (who is hosting next week). A must-read for doctors and patients alike

Neglect – A nurse tries to fill in the hole left when family and friends are far away from a hospitalized patient . (Great writing, this.)

Radiation Injury- Another Argument for Checklists

This week’s NY Times tells the heartwrenching tale of two patients who suffered radiation injuries during treatment for cancer. In one case, a 43 year old man being treated for tongue cancer recieved seven times the prescribed radiation – a lethal dose – to the head and neck. A woman recieved three times the recommended radiation dose to her breast, leading to a chronic festering wound that took over a year to heal – she ultimately died of her cancer. In both cases, there were multiple missed opportunities to identify the computer error and prevent the injury.

I encourage you to read this excellent article which explores both the hope and the risks of radiation therapy.

Stories like these cry out for a technological solution – a failsafe mechanism on the expensive and complicated equipment used to target and deliver radiation to treat cancerous tumors.

And yet, I found myself wondering if a simple checklist might have worked just as well.

We already use checklists when giving chemotherapy, with each dose being checked by two individuals prior to its administration.

We need a similar nationwide standard for radiation therapy.
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Orac does a thoughtful analysis of the article, including a call for checklists. THe discussion in the comments section is well worth reading

Sondheim, b.i.d.*

Take your morning dose with your musical theater class doing a read/sing through of Side by Side by Sondheim. (Everyone sounded great!)

Take your afternoon dose with your best college buds seeing A Little Night Music. (Angela Lansbury is perfect, Catherine Zeta Jones born to the role and Alexander Hanson the sexiest Fredrik ever. The supporting cast is equally excellent. Go see it!)

Food interactions (such as lunch at La Masseria) can occur, and may increase the level of joy.
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b.i.d. – Doctor speak for twice a day

Our Spaghetti Sauce

Every family has their standard spaghetti sauce recipe, and this is ours. It’s hearty meat sauce that is rich in flavors and perfect for a spaghetti dinner. The recipe is based on one from my mother-in-law Irene, lightened a bit by using less olive oil.*

We vary the meat combo depending on what we have in the freezer or can find at the market, but try when we can to use at least one other meat besides beef, usually pork. The quantities of meat are non-exact since that’s the way you find them at the market, but overall its about 2 lbs.
Of course, you could make the sauce by using ground turkey or chicken, but then it wouldn’t be our sauce now, would it? It would be yours.

Our Spaghetti Sauce

Put a the teapot filled with fresh water. Open one large 1 lb 13oz can of Italian tomatoes and buzz them on the food processor with a large 1 lb 13 oz can of tomato puree. (Alternatively, just open 2 cans of crushed tomatoes).

Heat 1/4 cup olive oil in a large saucepan on high heat. Add 8-10 minced garlic cloves and 1 tsp fennel seeds and cook, stirring, till they begin to turn color. Immediately add 1 lb lean ground beef, 1/2 to 1 lb ground pork or Italian sausage (removed from casings) and 1/2 to 1 lbs ground veal, and cook, stirring frequently.

While the meat is cooking, put two cubes of beef bouillon into a large pyrex measuring cup and add 2 cups boiling water, stirring to dissolve the cubes.

Just when the meat loses its redness, stir in 3 tbsp flour and the bouillon. Allow to thicken about a minute. Add the tomatoes and stir. (To stretch the sauce further, add a can of tomato paste and a can of water). Add spices – 1 tbsp salt, 1 tbsp sugar, ground black pepper +/- crushed chili pepper to taste, 1 tsp dried oregano (or more to taste), 1 tsp dried basil or 1/4 cup fresh pesto (we almost always use the pesto since we usually have some homemade in the freezer) and 1 cup finely chopped parsley.

Bring the sauce to a boil and simmer for at least an hour.

This recipe makes enough for 2 lbs of spaghetti and tastes best the second day. It freezes well.

For leftovers, dice eggplant and salt it. Toss in oil and garlic and lightly brown. Toss with leftover spaghetti. Spread 1/2 cup mozarella and sprinkle with Parmesan and bake 1/2 hour.
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*The original recipe called for 1/2 cup olive oil. Irene tells me her Italian friend told her you have to use a lot of oil in your spaghetti sauce, and indeed recipes for Neopolitan Tomato Sauce call for 1/2 cup oil. One of these days I’ll make it that way and see if it makes a difference. If any of my Italian readers want to comment, feel free.

Cycling Home from Siberia

Rob Lilwall rode from Siberia to London on a bicycle. That’s about (are you ready?) 30,000 miles, if you include a few little detours to places like Australia, Pap New Guinea, Tibet and Iran. The trip took over three years.

You can get a taste for the trip on Rob’s Website. Rob has also written a book about his experiences (only available right now in the UK and online), and National Geographic aired a 6 part series about the trip on their Australian Adventure Channel.

Rob stopped in at Mr TBTAM’s school today and gave what I hear was an incredibly fascinating and motivational talk to the kids. Afterwards, Mr TBTAM took Rob and his wife for a bike ride along the West Side Greenway, which for Rob, I suppose, was sort of like riding through the mountains of Tibet, but different.

Klezmer Jazz at Mehanata Bulgaria

Thanks to our friend Paulie for inviting us to hear him play Klezmer Jazz at Mehanata Bulgarian Bar along with his classmates and teachers from SUNY Purchase. It was a rousing night of music, food and drink. Not to mention meeting a few genuine Bulgarians in the crowd, who told me the music was just like what they listened to at home.

Mehanata Bulgaria is a great place to go to listen and dance to gypsy music, share a hookah and eat Bulgarian food. We all shared a plate of sausages with fried potatoes, grape leaves, cucumber salad and a red pepper puree that was delish. And it cost only $8.99!

Oh, and in case you’re wondering – Paulie is the cool one playing bass.

When Hair Loss Strikes…

a doctor is a girl’s best friend, according to a recent article in The NY Times.

The author had what sounds like a case of tellugen effluvium, a temporary loss of hair that occurs when a large number of hair follicles decide to cycle together, usually as a result of stress or sudden hormonal shifts (like giving birth). Fortunately for her, the follicles all cycle back in eventually.

She then goes on to discuss on of the more frustrating causes of hair loss in women – androgenetic alopecia, or male pattern baldness.

I see androgenetic alopecia not infrequently in women who came convinced that they have a treatable hormonal problem. Unfortunately, I’ve yet to find any hormonal abnormalities in these women other than menopause and perimenopause. I have had limited success using hormone replacement for the problem, although I do offer it as a trial. I generally offer Minoxidil, but patients seem to have trouble following through on its use. I tend to avoid Propecia, a drug use in male baldness, since we have limited experience using it in women.

Some of my patients with androgenetic alopecia have had success stemming further hair loss with Spironolactone, a diuretic anti-hypertensive that has the added effect of blocking the testosterone receptor in the skin.  It’s not FDA approved for this indication, but we’ve been using spironolactone for years to treat hirutism, as well as for its diuretic effects on pre-menstrual bloating. Spironolactone can cause birth defects in male fetuses, so I never prescribe sprironolactone without concomitant hormonal contraception in women in their reproductive years.

Of course, there are other causes of hair loss – these are just the two most common ones. If you think you losing your hair, see your doctor. Sometimes hair loss can be a symptom of an underlying medical condition such as thyroid disease, although in my experience thyroid problems are more often diagnosed on routine screens before hair loss ever becomes a problem. Rarely, a testosterone-secreting adrenal or ovarian tumor can present with hair loss, though usually this is accompanied by other signs of androgen excess.

Other causes of hair loss are alopecia areata, (thought to be an autoimmune disorder), medications (chemotherapy of course being the worst offender), fungal infections, hair processing chemicals and treatments, and other rarer causes.

Finally, don’t forget that hair loss can be one of the side effects of the much touted testosterone therapy in women.

Loyalties

Mabel: I hate half-hearted friends. Loyalty comes before everything.
Margaret:Ye-es; but loyalties cut up against each other sometimes, you know.

That’s the essence of Loyalties, a play currently running in an unlikely venue – the back room of a restaurant in Hunter’s Point, Long Island City. Think Andy Rooney and Judy Garland saying “Let’s put on a show!” – then give them an incredible script, a talented director and a wonderful group of seasoned equity and young non-equity actors and you’ve got a hidden gem of a production just two subway stops off Broadway.

The play itself is a British drawing room drama by John Galsworthy, the author of the Fosythe Saga. Think Noel Coward, but from the inside. At the play’s outset, money is discovered stolen from a room at a country manor during a weekend when the house is filled with guests. The crime’s victim happens to be the only Jew in the group and not entirely a likable character, and the accused a war hero, boyhood chum and all around good ‘old boy. Loyalties harden, soften and shift as evidence begins to mount against the accused and his friends and young wife are forced to decide where they stand.

Loyalties is presented by the Unity Stage Company and directed by Sofia Landon Geier, who has created a very sophisticated production on a shoestring. This is theater at it’s best – top-notch actors performing real drama without expensive sets, corporate backers or rehashed movie scripts. Congrats to Sofia for unearthing this little known gem of a play, which apparently played to smash reviews when it opened in 1922. It’s themes of racism, classism and group loyalties are, sadly, ever-relevant and particularly timely.
If you’ve never been to Hunter’s Point, seeing Loyalties is a chance to visit this hip gentrified Queens neighborhood. The 7 Train drops you just three blocks from the theater, and Vernon Boulevard is home to an increasing number of wonderful restaurants, including Blend, a Latin Fusion restaurant, Bella Via, a wonderful Italian place that I hear has fabulous brick oven pizza, and El Ay Si, which serves global “comfort food”. Every one of these restaurants was packed the night we went to see Loyalties, and my only regret of the night was that we had already eaten dinner at home.
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Loyalties is running till Jan 30 at the Parlor at Cassino Restaurant, 47-18 Vernon Blvd in Long Island City. For reservations, call 718-361-5858 or go online at Unity Stage.org.
Read more about the play and the cast in the Woodside Herald.

Mirena House Parties

Bayer Pharmaceuticals, the maker of the Mirena IUD, has teamed up with the Mommy marketing site “Mom Central” to sponsor house parties to sell women the Mirena IUD.

According to a warning letter sent to Bayer by the FDA about the worded content of the events –

The Mirena program is a live presentation designed for a consumer audience of “busy moms.” The program is presented in a consumer’s home or other private setting (e.g. private restaurant party) by a representative from Mom Central (a social networking internet site) and a nurse practitioner (Ms. Barb Dehn). The Mirena program submitted to FDA also references a presentation given by a fashion stylist (Ms. Angela Hastings) that immediately follows Ms. Dehn’s presentation regarding the use of Mirena. The script of Ms. Hastings’ presentation regarding fashion tips was not submitted to FDA.

The events start with an intro by a Mom Central rep –

This party was brought to you by Mom Central in partnership with Bayer HealthCare Pharmaceuticals’ Mirena which may help couples keep life simple!”…Barb Dehn is a practicing Women’s Health Nurse Practitioner, award-winning author and nationally recognized health expert from San Francisco. Barb is going to kick things off with a discussion about romance and how to find simple ways to reconnect with our partners.”

Nurse Barb gets the group talking about intimacy by asking icebreaking questions that include the following –

“If you didn’t have to worry about contraception, do you think you would be more likely to be intimate with your partner?”

“Do you think if you didn’t have to worry about taking your birth control everyday, it would help you be more intimate?”

Then, this scripted segway –

“So you mentioned that convenience and reliability are among the most important benefits of your birth control method. One strategy that I recommend for busy couples is choosing a birth control method that allows for spontaneous intimacy and which you don’t have to think about every day, such as the intrauterine contraceptive Mirena®.”

The FDA letter goes on to cite the scripted Mirena info for failing to disclose all the relevant risks of Mirena.

Here’s how one Mommy blogger describes the Mirena party she hosted last year-

Mom Central had found me through this blog and asked me if I would be interested in hosting an event sponsored by Mirena. As I welcome any opportunity to sit down with some girlfriends with some free food and drink, I was happy to accept….We had an amazing evening, talking about sex, fashion, and living a simpler life. I realized that we don’t actually spend a lot of time talking about sex and relationships. We laughed a lot but also went home with some great tips

Using moms to sell pharmaceutucals? Bayer has gone too far.