Big Pharma and Women in Government – Partnering for HPV Legislation

Much of the push to mandate coverage of the HPV testing and the HPV vaccine is coming from the Women in Government’s Challenge to Eliminate Cervical Cancer, a campaign that appears to be funded in part by the makers of the HPV test and HPV vaccine.

The Challenge, begun in 2004, has an ambitious agenda to eliminate cervical cancer in the United States, and seeks to “mobilizes state legislators to address cervical cancer prevention in their states.” According to a recent NEJM article entitled “Ethics and the HPV Vaccination“:

Women In Government, a Washington-based, bipartisan organization of female legislators, is leading a push to make HPV vaccination compulsory in every state. The group has issued recommendations for ensuring that the vaccine is accessible and affordable, including a recommendation that states add it to their Medicaid programs and encourage private health plans to cover it. The group follows in the tradition of breast-cancer activists, who have mobilized through many political channels to combat an illness that disproportionately burdens women.

Membership of the WIG, a 501 (c)(3) non-profit entity, includes female state legislators from all over the US. The group has a large list of policy issues they consider important – quite extensive and quite impressive. They appear to be taking on chronic kidney disease and higher education funding with a similar energy to their cervical cancer campaign. It’s an ambitious agenda that most certainly requires funding.

Who funds the WIG?

Like every non-profit, the WIG has lots and lots of corporate partners, and most of Big Pharma is there. But what the WIG also has is something called the Business Council, a tiny group of sponsors who seem to be much more intimately involved in the organization than most corporate sponsors of non-profits. From the WIG website –

The Women In Government Business Council is comprised of a small, select group of industry leaders. Business Council members support the overall mission of Women in Government and provide a private sector perspective to our programs. Members also play an integral role in planning for future growth, have the ability to attend our regional conferences, and support the financial stability of the organization.

Here’s the corporate membership roster of the Council – Digene (makes the HPV test), Merck (HPV vaccine maker), GlaxoSmithKline (HPV Vaccine maker), Wellpoint (heads the council), Exxon Mobile and Verizon. A full 50% of the membership stands to benefit from the legislative efforts of the Challenge to Eliminate Cervical Cancer. And one of the Council’s members, Digene, has a bit of a sordid past when it comes to partnering with women’s groups to forward favorable legislation.

Digene and the European Women for HPV

In 2004, a group called The European Women for HPV Testing began to campaign for legislation in England for national HPV screening. High profile female celebrities were recruited to the group to be spokespersons for the group and to lobby for legislation to approve the HPV test as primary cervical cancer screening. The European women for HPV Testing group even got mentioned in the British Medical Journal, in a manner similar to the NEJM mention of the WIG.

The problem was, the European Women for HPV Testing did not actually exist. As revealed by the Guardian Observer, the “group” was actually a front organization created on paper by the advertising company Burson-Marsteller and entirely funded by, you guessed it – Digene.

Partners with Aligned Interests?

Digene makes no bones about its strategy, which, according to their 2006 annual report, is to “expand beyond published data and medical guidelines to change the way healthcare is practiced“.

The WIG makes no bones that its strategy for tackling the issue of cervical cancer is “a collaborative approach… enlisting the support of stakeholders from across the globe” in its efforts. In their most recent report, the Challenge to Eliminate Cervical Cancer clearly stated that the publication was made possible by funding from Digene. But on none of its press releases about HPV does the WIG reveal its relationships with Digene, Merck or GlaxoSmithKline.

One could argue that without such funding relationships, the agenda of the WIG could not be forwarded. One could argue that in the case of cervical cancer, the interests of women and those of Big Pharma are aligned. One could argue that without Big Pharma to fund it, the Challenge to Eliminate Cervical Cancer would be nothing more than a nice name for a good cause.

But one could also ask whether the Challenge to Eliminate Cervical Cancer would even exist without Big Pharma. Both Merck and Glaxo have used PR firms to create advocacy groups whose mission is to increase awareness of HPV, and who “partner” with existing health and women’s advocacy groups. One is called The Partnership to End Cervical Cancer, and the other (which now appears defunct) is called Make the Connection.

And one could also argue that the financial ties between the WIG and Big Pharma puts the WIG in the position of being a lobbyist for Big Pharma rather than being political advocates for women.

Update on this issue here.
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Disclaimer: I use the HPV test in my clinical practice, although only for ASCUS triage and not for routine screening. I have not yet given the HPV vaccine to any patient, although we are discussing it, and given the recent recommmendations of the immune practices committee of the CDC, I expect I will be giving it. I still have a lot of concerns about the high cost of the vaccine, how long immunity will last, what will happen when the next generation of vaccines hits the market, and if it will really make a difference in the health of my patients, who for the most part, recieve regular pap smear screening.

Both the speed and sense of urgency accompanying the recent movement of the HPV test and vaccine into the healthcare arena has been startling to me, and I believe heralds a new age of unprecendented pharmaceutical marketing and influence. Physicians, patients and yes, even lawmakers need to be aware of these new strategies that are being used to influence us.

Category: Second Opinions

Mammograms – The Brits vs the Yanks

It appears that my recent post about the Lancet study has stirred things up a bit over at Dr Crippin’s blog. The trans-Atlantic discussion in the comments section is quite an interesting read, and I encourage you to head one over there for it. From what I read, we Americans have slightly different recommendations for mammogram screening than do our counterparts in the UK.

Mammograms in America

We recommend routine mammograms every 1-2 years in women age 40 and over. (Read the NCI justifications for this recommendation here) Although this screening is not universally free, it is covered by all insurances (some annually, some every 2 years). For women without insurance, there is a free national screening program, and many local screening programs exist as well. Women can self–refer, but must identify a physician to receive the mammogram report.

Mammograms in Britian

In the UK, breast cancer screening appears to be free to all for women through the NHS Screening Programme, but is not routinely offered until after age 50, and then every 3 years:

The NHS Breast Screening Programme provides free breast screening every three years for all women in the UK aged 50 and over. Around one-and-a-half million women are screened in the UK each year. Women aged between 50 and 70 are now routinely invited.

Because the programme is a rolling one which invites women from GP practices in turn, not every woman will receive an invitation as soon as she is 50. But she will receive her first invitation before her 53rd birthday. Once women reach the upper age limit for routine invitations for breast screening, they are encouraged to make their own appointment.

Higher risk women can be identified by their physicians and referred to more intensive screening programs in the UK. The women in these programs either have BRCA mutations or a 20% or higher chance of being a BRCA carrier. The intensive screening programs offer individualized risk assessment and screening, including mammography, sonograms and MRI.

It appears from the NICE guidelines (see below) that only women who raise concerns about their family history to their GP get referrals to high risk centers:

1.3.1.2 Healthcare professionals should respond to women who present with concerns but should not, in most instances, actively seek to identify women with a family history of breast cancer.

Some thoughts

Both the UK and American program recommendations are evidence-based, but appear to be relying on either different evidence, or making different conclusions based on the same evidence. Perhaps concerns about liability and very strong breast cancer awareness and concerns among American women are driving our guidelines a bit more than those in the UK.

The increase in mammogram use in the US and the UK has been associated with a decline in mortality from breast cancer in both countries. Advances in treatment, however, may be as much responsible for the decline in mortality, since in the US, the rate of new advance breast cancers has not changed, despite a marked increase in diagnosis of early stage and in-situ cancers.

One could argue that the increase in mammograms has done nothing more than diagnose early indolent cancers that would never have killed anyone. It’s a salient argument, but until we have some way of distinguishing who is going to get the aggressive vs indolent tumors, it doesn’t change screening. However, advances in proteomics and DNA testing are rapidly being made, and currently are driving treatment decisions so that women with more agressive tumors get more agressive treatments.

Someday, we’ll have a better screening than mammogram. It may be MRI, it may be a serum test. It may even be a genetic test to identify the women at risk, so that those at no risk can avoid mammograms altogether. Wouldn’t that be great?

Category: Second Opinions

Mammograms in Women Under 50 – The Lancet Study Reviewed

That graph up there shows the main outcomes of the AGE Trial, a large study of mammography screening in England that asked the question “Does offering mammograms to women in their 40’s save lives?” The dotted red line represents the mortality from breast cancer in women offered mammograms annually between ages 40 and 48 through the National Health Service (or NHS). The solid line represents the control group of women who were not offered mammogram screening by the NHS until after age 50.

The investigators are interpreting that graph to mean that mammograms in women under age 50 are not worth doing.

Let’s talk, shall we?

The study, which was published Dec 9 in the Lancet, randomized 160,921 women on a 1:2 basis to either annual mamograms from age 40-48 or to a control group of “usual care”, which in the NHS is an invitation to a first mammogram between ages 50-52. Deaths were identified through the NHS central registry for a mean follow up of 10.7 years.

There was a 17% reduction in breast cancer mortality in the early screen group. (That’s the graph up there)

As it turns out, only 69% of the women invited to screen actually came for the initial screening, and overall, only 81% of them ever got a mammogram during the study. The women who never showed up for the mammograms had a higher rate of breast cancer deaths than those who got the screening. When adjusting for these two factors, the investigators found that women who actually showed up for the early mammograms had a 24% reduction in mortality from breast cancer compared with the control group.

Sounds pretty clear, doesn’t it?

Well, unfortunately, it’s not. You see, neither the numbers I quoted nor the difference up there in the graph between the red and black lines is statistically significant.

Why not? Very possibly because the study wasn’t big enough to detect the difference in breast cancer mortality with enough certainty to call it real . You see, the NHS ran out of money and personnel partway throught the study, so the sample size was smaller than initially planned. Secondly, mortality in the control group was much lower than initially estimated, making it even harder to find a statistically significant difference with the smaller sample size. Here’s what the investigators said about this:

The power of the trial to show a reduction was diminished both by the smaller than planned sample size and by the lower than anticipated mortality from breast cancer in the control group (2·35 per 1000 vs 3·3 per 1000), resulting in a revised power of 60% to detect a 20% mortality reduction, and the CI does not exclude a reduction of 34% or an increase of 4%.

Most studies are powered at 80%, meaning that, going into the study, there is an 80% possibility that the study has enough subjects to be able to detect a difference with 95% certainty between the groups. (or something like that – statisticians, feel free to correct me.). If the study is too small, then the odds are stacked from the get-go against finding anything to hang your hat on in terms of results. And that’s what happened here.

Finally, the mammograms performed in this study were below standard. Although the first screens were standard two view mammos, subsequent screens in the under 50 group were single view only. This was done in an attempt to diminish radiation dose, but likely resulted in lower detection rates in the screened group, since single view mammograms are less sensitive and specific than two view mammos. (Current standards in both UK and US are two view mammograms.)

The end result is that the Lancet study failed to show a benefit to mammograms before age 50. What a shame – to do all that work, and have your final study size to small to detect a difference between your two groups with any confidence.

Perhaps to ease our disappointment with their study, the investigators did make a very nice graph of the clinical trials of mammograms in women under 40 to date:

For the lay crowd, what this graph means is that the risk of dying from breast cancer in women getting mammograms before 50 is smaller relative to those who wait till after 50. (The black boxes up there) But the 95% confidence intervals (the thin lines) of almost all of these studies crosses one, meaning that the protective effect of mamograms is still not statistically significant overall. However, I would say there is a clear trend to protection against dying in the early mammogram group, wouldn’t you? (All the black boxes except one fall below 1)

What about other outcomes?

Dying or living are not the only two possible outcomes that might be affected by earlier diagnosis of breast cancer. We all know that cancers picked up earlier are more likely to be amenable to breast-conserving surgery and less likely to require chemotherapy. I don’t know about you, but if I am going to get breast cancer, I would rather have it diagnosed at a stage where I can keep my breast and avoid chemo. Also, chemo can be associated with secondary cancers years later, something a 10 year study would not pick up.

Bottom line – this study adds little to our understanding of the role of today’s mammograms in women under age 50 as practiced in the United States. For my patients, I will continue to recommend mammograms every 1-2 years beginning at age 40, and annually at age 50 and above. I advise women with dense breasts to have digital mamograms and ultrasound in addition to mammography, especially if there is a family history of breast cancer.

Hopefully, the data from this latest Lancet study will not be used by the NHS to continue to deny this same screening to women in the UK. ________________________________________________

United States Preventive Services Taskforce recommendations for mammograms

NCI statement on mammograms in women under age 50

Info on Digital Mammography from the NCI

University Of Pennsylvania’s Med Page Today critique of the Lancet Study (excellent read)

Thanks to Rachel for pointing the Lancet article out to me.

Category: Second Opinions

Joe’s Calamari Marinara

You think I’m a foodie? Nah. I’m chump change compared with my brother Joe, who is the genuine foodie of the family.

Joe has actually worked in real restaurant kitchens, has close friends who own restaurants, and knows wine because he used to sell it in Northern California. And while Joe may love to read cookbooks, he doesn’t need to cook from them like I do. He cooks like the real chefs do, with instinct, flare and a sense of what’s right and what goes with what. His wife Rachel is the same kind of cook, and together, they can make a mean meal. Dinner at their house is an event that goes on for hours, with one course after another woven together with the thread of fine wine…

Joe also loves to wax prolific about food and wine. Get him going, and the phrases”hit it with a little olive oil” and “crank up the heat” and “floral lilt” and begin to creep into his otherwise colloquial speech. By the time he’s done, you’ve either got to start cooking right away or run out to the nearest fine restaurant to satisfy your cravings.

Joe made a delicious Calamari Marinara appetizer on Friday night. I think I’ll let him tell you himself how to make it. He’s our own Jamie Oliver, and we love him. Enjoy!

Calamari Marinara ala’ Joe (Click on the arrow to view video. Requires Flash Player)

Category: Food

Joe Waxes Calamaric

You think I’m a foodie? Nah. I’m chump change compared with my brother Joe, who is the genuine foodie of the family.

Joe has actually worked in real restaurant kitchens, has close friends who own restaurants, and knows wine because he used to sell it in Northern California. And while Joe may love to read cookbooks, he doesn’t need to cook from them like I do. He cooks like the real chefs do, with instinct, flare and a sense of what’s right and what goes with what. His wife Rachel is the same kind of cook, and together, they can make a mean meal. Dinner at their house is an event that goes on for hours, with one course after another woven together with the thread of fine wine…

Joe also loves to wax prolific about food and wine. Get him going, and the phrases”hit it with a little olive oil” and “crank up the heat” and “floral lilt” and begin to creep into his otherwise colloquial speech. By the time he’s done, you’ve either got to start cooking right away or run out to the nearest fine restaurant to satisfy your cravings.

Joe made a delicious Calamari Marinara appetizer on Friday night. I think I’ll let him tell you himself how to make it. He’s our own Jamie Oliver, and we love him. Enjoy!

Calamari Marinara ala’ Joe (Click on the arrow to view video. Requires Flash Player)

Category: Food

Grand Rounds: Vol 3, No 11

Le venin de serpent, antidote au poison
Pseudo-Galien, Kitâb al-diryâq (Livre de la thériaque). Jazirah ?, 1199.

Grand Rounds is up over at The Antidote, a website that is subtitled “Counterspin for Health and Haalthcare news”. Grand Rounds is a weekly compilation of the best of the medical blogosphere. The target audeince for grand rounds is the educated but nonmedical reader. If that’s you, then head on over to The Antidote and see what the offerings are this week.

The Antidote is written by Emily DeVoto, Ph.D., and is an example of a well-written blog that makes a real contribution. Many thanks to Evelyn for tackling Grand Rounds this week, and for accepting my contribution at the last hour – or was it 2 am?

Image from the website of the Bibleoteque Nationale de France
Category: Second Opinions

Grand Rounds: Vol 3, No 11

Le venin de serpent, antidote au poison
Pseudo-Galien, Kitâb al-diryâq (Livre de la thériaque). Jazirah ?, 1199.

Grand Rounds is up over at The Antidote, a website that is subtitled “Counterspin for Health and Haalthcare news”. Grand Rounds is a weekly compilation of the best of the medical blogosphere. The target audeince for grand rounds is the educated but nonmedical reader. If that’s you, then head on over to The Antidote and see what the offerings are this week.

The Antidote is written by Emily DeVoto, Ph.D., and is an example of a well-written blog that makes a real contribution. Many thanks to Evelyn for tackling Grand Rounds this week, and for accepting my contribution at the last hour – or was it 2 am?

Image from the website of the Bibleoteque Nationale de France
Category: Second Opinions

The Metropolitan Museum by Night and a New Salad

I have a new favorite place to be – The Metropolitan Museum at night. I just found out that it is open Fridays and Saturdays till 9pm, and if you ask me, that’s a wonderful time to go. There are no crowds and less tourists, so you feel like you own the place. Plus all their restaurants serve dinner, so you can really make a nice evening of it.

And that’s exactly what we did this past Friday night. Fridays are girls’ night in our family, since Mr TBTAM plays tennis, and we usually order in and see a chick flick. But my oldest daughter had a class assignment that required her to see some paintings at the Met, so we met her there as she was finishing her assignment in the European galleries…

“I made a new friend,” Emily told me, and pointed out the security guard in the corner, who smiled and nodded to me. Turns out that he had taken great pride in helping my daughter find the 15 or so paintings she needed to see. As she would be looking at a painting, he would come up to her “I found your next one!” He clearly loved the collection, knew which room each artist was in, which paintings were out on loan and which were off in storage.

As I was talking to him, another group of students he had been helping came up, and he introduced them to my daughter so they could all compare notes and help each other out. What a nice man! I wanted to talk to him so more, see if he would let me take his picture and do a blog post about him, but my girls decided that I was taking this blogging thing too far, and dragged me away…

I sulked a bit and then we went to see my Vermeers.

I had first seen the Vermeers a few years back, shortly after reading Girl with a Pearl Earring and seeing the movie. I knew that much of the story I had read was not entirely factual, but it had compelled me to learn about this man’s life and his paintings. And so, I decided to go to the museum one day, alone, specifically to see for myself these wonders Vermeer had painted.

As I was standing there, staring intently at the Young Woman with the Water Picher, imagining Vermeer painting her, I head a voice. “He was my relative”, said the man next to me, in a hushed and amazed tone.

Now, Vermeer had eleven children and so I imagine he has quite a lineage. It turns out that this man was a decendent of Vermeer through one of Vermeer’s sons (same last name, too) and lived in Minnesota. He was here in New York on business and had come to the Met on that day specifically to finally see his famous ancestor’s paintings.

It was one of those rare and eerie moments, when you and another person discover that you have been drawn to the very same place at the very same time, and for very similar reasons. I felt as if Vermeer himself had beckoned us, and might be standing there beside me. His descendant’s presence made the feeling even more real…

Since then, I have loved his paintings even more, and every time I visit the Met, I have to see my Vermeers.

After wandering around the European collections for awhile, the girls and I found our way to the sculpture garden, which is beautiful at night. The shadows accentuate the carvings, and the statues cast shadows on the floor and are reflected in the glass ceiling.

Next to the sculpture garden is the Petrie Court Cafe, and there we decided to have our dinner.

The restaurant is one of the pricier dining choices at the Met, but nice for a special occasion. They do a very lovely afternoon tea for which you usually need reservations, and I highly recommend doing it at least once. Sitting by the big glass doors overlooking Central Park in late afternoon and sipping tea is a real treat, especially if combined with a walk in the park and viewing some art. A wonderful way to spend a Sunday afternoon and best in high spring or mid October, I would say.

I had a glass of white wine, which felt somehow very special and decadent – maybe it was the setting – and the girls had tea. We shared cauliflower soup with truffle oil, a jicama and grilled shrimp appetizer, a very flavorful and moist chicken breast with risotto cake and veggies, and a pear and frisee salad with gorgonzola, roasted chickpeas and a white balsamic reduction.

Everything was delicious, but the salad was really something special. I had never had frisee alone in a salad, or even heard of roasting chickpeas. We decided then and there we were going to roast some of our own chickpeas and that I would try to replicate the salad at home the next night.

After dinner, the girls were too tired to head back upstairs to see the Americans in Paris exhibit, but we agreed to come back another Friday evening to do just that. We splurged on a cab ride home, during which Natalie regaled us with the plot of the book Chasing Vermeer. And we still got home early enough to see School of Rock at 9 pm. Okay, technically, it’s not a chick flick, but since Mr TBTAM doesn’t like it, it qualifies. Plus, we love Jack Black.

Frisee and Pear Salad with Roasted Chickpeas and Gorgonzola

This is still a bit of a work in progress, so comments are welcome. Use ripe pears and a very mild gorgonzola. (Mr TBTAM, who thought he hated blue cheese, loved this one.) The dressing I made tasted fine, but was more balsamic than what I was shooting for. Next time, I think I will add a little garlic powder or roast some garlic cloves along with the chickpeas. Some recipes for roasted chickpeas that I found roast at 450 degrees, others at 350 degrees. I compromised on 400 degrees.

1 can chickpeas
2 tbsp olive oil
salt and pepper
1/4 cup balsamic vinegar
1 cup white wine
2 tbsp honey
2 tbsp olive oil
1 bunch fresh frisee, rinsed and dried
2 ripe Anjou pears, peeled, cored and cut into sections
6 oz mild gorgonzola

Drain chickpeas well, then toss carefully with olive oil, salt and pepper. Spread out on a cookie sheet or roasting pan, and roast in 400 degree oven for about 20 minutes, stirring occasionally. Let cool.

Meanwhile, combine white wine, balsamic vinegar and honey in small saucepan and boil till reduced to about 1/4 cup. Cool. Add olive oil, season with salt and pepper.

Arrange frisee on platter. Cut gorganzola into individual serving size wedges. Arrange pears and cheese atop frisee. Scatter chickpeas over platter. Drizzle dressing and serve.

Category: Food / Considerations

The PMS Bath

The next time someone you love is in the throes of PMS…

No. Wait. Before the one you love is in the throes of PMS. You know, when you can see it starting. The short answers, the distracted look, the lethargic pose, the negative comments.

Before she starts lashing out at you, and you start lashing back, and someone says something they regret. And definitely before you ask “Are you getting your period?” Because if you haven’t learned it by now, never, ever as a woman in the throes of PMS that question.

Before all that starts, stop. Take a breath. Calm yourself down (because you can, she can’t).

And do something different this month.

Draw her up a nice warm bath, with some nice herbal bath salts. Light candles all around the tub. Put on a really nice CD – something happy but soothing. (I’m working on a PMS mix – I’ll let you know as soon as it’s done. In the meantime, if you have a Colin Hay CD, you can use that.) Sit a warm cup of cocoa and her book on a little table beside the tub, or on the sink or the toilet seat, whatever…

Then take her by the hand (and this is the hard part, because she is going to resist…) and lead her to the bathroom and show her what you’ve prepared for her.

At that point, she will say something like “Awwww…” or “This is so nice..” or “Cocoa? You made me cocoa?” And she will slip into that nice warm bath, and listen to the great mix that you’ve made for her (it’s coming, I promise), and read her book for an hour.

And when she’s done, she will feel better.

Now, isn’t that better than asking “Are you getting your period?”

Category: Considerations

The PMS Bath

The next time someone you love is in the throes of PMS…

No. Wait. Before the one you love is in the throes of PMS. You know, when you can see it starting. The short answers, the distracted look, the lethargic pose, the negative comments.

Before she starts lashing out at you, and you start lashing back, and someone says something they regret. And definitely before you ask “Are you getting your period?” Because if you haven’t learned it by now, never, ever as a woman in the throes of PMS that question.

Before all that starts, stop. Take a breath. Calm yourself down (because you can, she can’t).

And do something different this month.

Draw her up a nice warm bath, with some nice herbal bath salts. Light candles all around the tub. Put on a really nice CD – something happy but soothing. (I’m working on a PMS mix – I’ll let you know as soon as it’s done. In the meantime, if you have a Colin Hay CD, you can use that.) Sit a warm cup of cocoa and her book on a little table beside the tub, or on the sink or the toilet seat, whatever…

Then take her by the hand (and this is the hard part, because she is going to resist…) and lead her to the bathroom and show her what you’ve prepared for her.

At that point, she will say something like “Awwww…” or “This is so nice..” or “Cocoa? You made me cocoa?” And she will slip into that nice warm bath, and listen to the great mix that you’ve made for her (it’s coming, I promise), and read her book for an hour.

And when she’s done, she will feel better.

Now, isn’t that better than asking “Are you getting your period?”

Category: Considerations

The HPV Test: A Piece of My Mind

peace of mindWhat’s the new mantra for marketing health care testing to American women? “Peace of mind”.

That’s right. Forget medical necessity. Forget that your doctor feels it is not needed. Or that your insurance may not cover it. Get the test “for your peace of mind”.

Digene is tapping into women’s inherent anxiety and fears about cancer by suggesting that they routinely get the HPV test, even if their pap is normal, so that they can sleep at night.

Digene’s web site for women is a cross between Women’s Day Magazine, 20/20 and a pharmacetical rep training manual. It’s absolutely brilliant marketing. Chock full of anectodal survivor stories to warm the heart and scare the bejesus out of the reader. If you weren’t worried about cervical cancer before you came to the site, you sure are now. Then, once they’ve got you good and scared, they sweep in on the white horse to offer you the cure – the HPV test.

But there’s one problem – Routine HPV testing, although FDA approved, is not the only strategy recommended for cervical cancer screening. And there’s the little problem of that darned doctor…

Not to worry. Digene is going to coach you so you can convince your doctor to give you the test. Here’s just a little bit of their advice:

Call your doctor’s or nurse’s office before your next exam to find out if the HPV test is offered as part of routine screening for cervical cancer, along with the Pap. Remember: Make sure the office understands that you want the HPV test no matter what the Pap test shows. Some doctors and nurses only order an HPV test when your Pap results are inconclusive (called an “ASC-US” Pap).

If your doctor or nurse says the office does not order HPV testing for all of its patients who are 30 and older, indicate you’d like them to make an exception for you.

If your doctor or nurse (or the office staff) responds by saying he/she doesn’t think routine HPV testing is necessary, the simplest way to respond is to say that you would still like to have the test “for my extra peace of mind.”

That didn’t work? No problem. Digene has a full page of strategies for women to use to convince their doctor to give them the test. I swear, it reads like a pharm rep training manual. Every possible response from the doctor is covered, and Digene has an answer for each one of them. And they all end with telling the doctor that you want the test for “extra peace of mind.”

“Talk to your doctor” has turned into “Sell our test to your doctor”.

And the survivor stories? Well, if you have ever read the cancer stories in Women’s Day or Glamour, you know how they read. Anectodal horror stories that will convince anyone reading them to run out and get the HPV test right away. All implying that if these women had gotten an HPV test, things would have been different. Maybe…

Digene can take the story of a woman whose HPV test added absolutely nothing to her health care and make it sound like a survivor story. This woman got not just one, but four HPV tests over three years for a transient HPV infection that never resulted in a single abnormal pap smear or any need for treatment. Here’s what she says about it:

This experience taught me the importance of not being afraid to ask questions and make decisions with my doctor, rather than letting him make all of the decisions for me. Demanding the HPV test may have saved my life.

She never had an abnormal pap. She did not develop cervical cancer or even cervical dysplasia. But the HPV test “may have saved her life”.

Now, I could give you a few anectodal stories about women whose HPV test was negative, but whose pap showed high grade dysplasia. (No test is perfect, not even the HPV.) Or women whose relationships were broken up by an HPV test that added nothing to their health care. Or physicians who do the HPV test on every patient, only to have patients get angry at them for finding a condition that basically has no cure and hasn’t changed anything except to creat anxiety. I could even make a website about it, and coach you into talking your doctor out of that routine HPV test.

But I won’t.

Because you should talk to your doctor about the HPV test, not me. Someone who hopefully knows you, knows about the test, and together with you can decide if having the test is right for you. Because routine HPV testing is not necessarily the best strategy for every patient and for every medical practice.

And for the record, do I ever order HPV testing on a woman with a normal pap smear? Sure I do. But that’s a decision I make on a case by case basis, one that the patient and I make together after discussing the reasons for and against the test, the cost implications, and what we will do about the results if they are abnormal.

It’s not a decision she has been talked (and coached) into by a company trying to market that test.
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For patient information about the HPV test, see the American Cancer Society Website.

Clinician information from the Centers for Disease Control.

Financial disclosure: I used to own Digene’s stock, and even made a few bucks on it back before the test was being used in clinical practice. I knew HPV testing was going to become part of women’s health care. I didn’t know Digene was going to annoy me this much…

Category: Second Opinions

A Brazilian Thanksgiving Eve : Moqueca de camarão, Mango & Avocado Salad and Pudim de leite

I know, I know. It’s ridiculous. But every year, on the night before Thanksgiving, we have a dinner party.

You see, my friend Andy and his daughter are clowns in the Macy’s Thanksgiving Day Parade. So their family stays with us the night before in order to be able to get to the parade on time (5:30 am for the clowns), and we all have a nice dinner together. For the past two years, our friends in from Maine have also joined us. It’s a wonderful, low-key evening, and I look forward to it every year. I try (usually unsuccessfully) to keep the fare light, and we all try to end the evening early so the clowns can get to bed.

Of course, part of the reason I can enjoy Thanksgiving Eve is that I do not have to cook dinner the next day. We head to Philly on Thursday morning, and tag team two family back-to-back dinners. (Don’t ask… ) I usually bake a pie and bring some sides, but that’s the limit of my responsibility.

This year’s Thanksgiving Eve dinner was a challenge. Isabelle cannot have anything fermented or with cow’s milk, and one of the kids is now a vegetarian. It took awhile, but I finally hit on the perfect menu – Brazilian fish stew (most of which is made ahead), and mango and avocado salad with a lime vinaigrette. Dessert was flan with fruit. (Oops, Isabelle. I got so caught up with the Brazilian theme I forgot about the milk. Did you even have dessert?) We served a white pinot, but I don’t know if this was the best choice of wine. Suggestions are welcome…

The kids set the table with the fancy dishes, and we put up votive candles all around the apartment. Emily S. Arrived early and helped us set up the appetizers (Thanks, E.S.!), which were crostini topped with chopped liver or white bean and sage puree, olives, baby carrots, apple slices, roasted peppers in oil and a wonderful sheep’s milk cheese from Fairway.

I had a great time. This year, the clowns were in bed by 10:30 – not too bad – and the rest of us hit the sack by 11:30. Thanks, Linda for doing the dishes. We missed you Sam, but hope to see you at Christmas. Happy Thanksgiving!

Moqueca de camarao (Brazilian Fish Stew) (See original recipe at Epicurious.com)

This goes down in culinary history as one of the best dishes I have ever had. It’s a great dish to make to amaze your friends, and so easy.

The original recipe calls for pureeing the diced tomatoes, but I chose to keep them whole. I’ve also re-written the recipe to reflect how I prepared it ahead. If you are making it just for yourself, and not ahead of time, use the Epicurious version. I was not able to find dende oil (red palm oil) at my usual sources (Fairway and Gourmet Garage), but am determined to get it before I make this again. I cannot imagine this stew could taste any better than it already does, but from what I have read, that oil puts the flavors over the top.

Sauce
1 1/2 tablespoons olive oil
1 medium onion, finely chopped
1 green bell pepper, finely chopped
1/2 teaspoon cayenne
1 tsp salt
1 tablespoon coarsely chopped fresh cilantro
1 (14- to 15-oz) can diced tomatoes including juice

1 cup well-stirred canned unsweetened coconut milk (to be added just before adding shrimp)

Shrimp marinade
1 1/4 lb large shrimp in shell (21 to 25 per lb), peeled and deveined
1/4 teaspoon black pepper
1/2 teaspoons salt
2 garlic cloves, minced
1/4 cup fresh lemon juice

Last-Minute Additions
1 tablespoon dende (palm) oil
4 tbsp coarsely chopped cilantro

Accompaniment
Cooked white rice (I used Basmati)

Cook onion and bell pepper in olive oil in a 12-inch heavy skillet over moderately low heat, stirring, until softened, 8 to 10 minutes. Add cayenne, 1 tablespoon cilantro, and 1 teaspoon salt and cook, stirring, 1 minute. Add tomatoes and simmer briskly, stirring, until mixture is very thick, about 15-30 minutes.

Make marinade and keep, covered, in the fridge till you are ready to use it.

About 40 minutes before serving, start your rice cooking. Then toss shrimp with marinade in a large bowl, and let sit in fridge, covered, for about 20 minutes. (Not any longer, or you will have ceviche).

5-10 minutes before serving, stir coconut milk into sauce and bring to a boil. Add shrimp mixture and cook, stirring, until shrimp are just cooked through, about 3 to 5 minutes. Stir in dende oil and remaining 4 tablespoons cilantro and season with salt and pepper.

Plate individually, first putting rice into a small bowl, then inverting it onto the plate. Spoon the stew over the rice. Keep bowls of stew and rice on the table, though – everyone will want seconds!

Mango and avocado Salad with Lime and Honey Vinaigrette

salad greens (We mixed red lettuce with mesclun)
large ripe mango, halved, pitted, peeled, sliced
2 small avocados, halved, pitted, peeled, sliced
Juice of 1/2 lime
3 tbsp honey (Depends on how tart or sweet you like it.)
1 tbsp hot water
½ cup olive oil
Salt
Pepper

Whisk the honey and lime together with the hot water. Gradually whisk in the olive oil. Season with salt and pepper to taste. Toss greens with ¾ of the dressing. Arrange mango and avocado on top of greens and drizzle remaining dressing over them.

Pudim de Leite (Brazilian Flan)

There are many ways to make flan. Some recipes use eggs, others add corn starch or use cream instead of milk. All start with caramelized sugar, which forms the base (and later, the top) of the dish. This is the Brazilian version, from Maria Brazil web site, with a few modifications on my part. You can use a ring mold if you are being traditional. I used a Pyrex glass dish.

1 cup sugar (for the caramel)
1 12-oz cans sweetened condensed milk
Equal volume of regular milk (use the can to measure)
3 eggs
1 quart strawberries, washed and drained
Lovely cookies

Place 1 to 2 inches of water in a large roasting pan. Place the pan in the oven and preheat to 325°.

Put the sugar into a heavy saucepan. Heat over medium high heat, stirring almost constantly, until the sugar melts into a golden brown caramel. (Watch carefully, it goes slowly, then turns color quickly.)

Pour carefully into pyrex dish or mold. (Listen for cracking noises as the sugar cools and cracks!) and spoon it a bit up the sides of the dish. Be careful not to burn the sugar and yourself. Let it cool.

Whisk together the condensed milk, regular milk and eggs. Pour this mixture through a fine sieve into your prepared dish. (This gets any little egg lumps out).

Place the dish carefully into the center of the roasting pan with water. Bake for about 1 hour. (You will know it is done when you can insert a knife inserted into the center without the custard pooling into the defect you made.) Carefully remove the dish, Let it cool to room temperature and then place in refrigerator for at least 6 hours or overnight.

Just before serving, run the tip of a knife around the inside of the mold. Place a deep platter over the mold and invert: the flan should slide out easily. If not, give the mold a firm but careful shake. Cut into squares. Plate with a spoon of caramel sauce on top, two strawberries and a little cookie.

Serves about 10.

Category: Food

The Perfect Scone? Sorry Delia, not quite…

In our first attempt at making the perfect scone, my daughter Natalie and I made some pretty tasty scones, but the texture was not as light as we’d hoped. We tried Ina Garten’s scones next, and came up with a lighter scone that seemed a bit dry.

Thanks to my reader’s comments and a little research, I’ve figured out that the scone I am looking for must be an English scone, which it seems, is more akin what we Americans would call a biscuit. Given that the first scone I’d ever had was in Bath, England, that made sense to me.

So last weekend, at the suggestion of both Waynetta and Chairwoman, I finally tried Delia Smith’s Scone Recipe (complete with photos, here). Delia is sort of the Julia Child of Britian, a TV chef who made cooking seem simple, and whose recipes are known to be tried and true. (You can read her BBC bio here). I figured that if Delia didn’t have the right British scone recipe for me, no one would.

The first thing I noticed about Delia’s recipe was that she recommends the butter be at room temperature, which goes agains everything I’ve come to learn about making pastry, and is the exact opposite of the recommendation in my Professional Chef, namely, to put the butter back in the fridge after cutting it up to be sure it stays cold until the very last minute. This was my first inkling that perhaps Delia’s recipe would not be the best…

I decided to stick with the Professional Chef, and kept my butter cold. Otherwise I followed Delia’s recipe exactly, even using castor sugar and a round biscuit cutter (except I added chocolate chips).

The first batch was made with daughter and her friend. The kids took a little longer than I wanted working the dough, and it really became too cookie like. So I made a second batch myself, working like lightening to keep the dough light. Mine is on the left up there, and the kid’s scone is on the right.

They look great, and the flavor was great. But you know what? The scones were too dry. I know scones are meant to be eaten with clotted cream or jam, but still I was disappointed. I think the recipe I seek has a bit more liquid than Delia’s. In fact, when I look at biscuit recipes, they definitely have more liquid.

So it’s back to the drawing board. Next up, I think I will try the Cook’s Illustrated scone recipe. If anyone knows where I can find it, do let me know.

Of course, it may be that what I am looking for is not a scone, and perhaps doesn’t even exist. But I have this memory of a warm, light, not dry scone with clotted cream sometime in my culinary past (perhaps in Bath?), and I’m determined to make it…

Addendum: I Found it! The Pefect Scone.

Category: Food

Suzanne Somers on Larry King Live

Suzanne Somers appeard on Larry King last night, supposedly to take on her critics in the medical establishment who, like me, are concerned about the misleading medical information contained in her best selling books. (See my recent post on suzanne and the bio-identical hormone hype.)

What could have been an informative debate ended up being a cat fight that did nothing to inform American women about the real issue. That issue is the unfettered promotion of bio identical hormones as a risk-free cure-all for everything from depression to cancer to getting old.

Neither Suzie nor her critics got to say more than a few uninterrupted words at a time, and Larry seemed unable to control his guests or to frame the debate. When he did attempt to give some context, he focused on the personal battle between two of the guests, a physician and an unlicenced practitioner of anti-aging medicine. (You could read the transcript here, but don’t waste your time.)

Wolf Utian, the head of the North American Menopause Society, and probably the most objective of the guests, was unfortunately placed at a distinct disadvantage given his consultant work for Wyeth and his society’s Big Pharma support. (One more argument for disentangling the medical profession from Big Pharma.)

The fact that Wyeth appears to be leading the charge against Suzie and her anti-aging consituents is unfortunate. Wyeth’s involvement only serves as a lightening rod that distracts from the real issues and hurts the credibility of those in the medical establishment who want to see the FDA regulate the multi-billion dollar anti-aging and compounding pharmaceutical industries. These folks love to play themselves as the little guy against Big Pharma, and as long as Wyeth stays in the fight, that’s how they get to frame it.

This is not about protecting Big Pharma or defending Prempro. It is about informing women. Wyeth needs to step out of the fray.

Category: Second Opinions

The Seven Songs Music Meme

Okay, it’s been over a month since Tundra PA tagged me for this meme, and it’s about time I got around to answering it.

A meme is an idea that is passed from blog to blog, and doing a memes are a great way for bloggers to get to know one another and to share a bit of themselves that they otherwise might not think to do.

This meme asks that I list seven songs that I am currently listening to, and then to tag seven other bloggers. This meme is so old, everyone else has probably already done it by now. But if you haven’t done it yet, consider yourself tagged and do it already, it’s a lot of fun! (Linda and Main Mama, this means you..) Thanks, Tundra PA, I really enjoyed this one…

Click on the red links to hear the music or view the album…

1. Graceland – Paul Simon

I never tire of listening to this gem, truly one of the best albums ever released. The music is fantastic, a mix of American and African rythyms plus a little Ladysmith Black Mombasa, and the lyrics are sheer poetry. Not to mention alliteration – “the boy in the bubble and the baby with the baboon heart”.

I know every song on this album by heart, and have even invented some cool moves for the “whoop, whoop” parts of the song I Know What I Know. One time we were driving to Maine with our friends, two cars playing tag along Rt 95, all the kids somehow in our car. Our friends passed us at one point, and later told us they knew exactly what song we were listening to because everyone in the car was doing that “whoop – whoop” move.

My favorite memory of the Graceland album, though, is from my fourth year of ob-gyn residency, in the days when in vitro fertilization was in its infancy. On this particular day, we were implanting embryos from our very first batch of frozen embryos. The patient was special to all of us, having gotten to know everyone intimately over the course of her treatment. (These were also the days before IVF became a mill.). Both the patient and our chief loved music, and she used to bring in mix tapes for him whenever she came for her appointments.

On the day of the embryo implantation, our patient dressed herself in a beautiful cotton nightgown instead of the hospital gown. She insisted that we turn down the lights so that only the procedure light was on. Then, while her tape player played These are the Days of Miracles and Wonder from the Graceland album, my chief implanted the embryos. It was almost too intimate and beautiful a moment for words.

She conceived, of course, and went on to deliver healthy twins. A miracle and a wonder, truly.

2. Flower Duet from Delibe – Lakme (Natalie Dessay et al)

Remember that sweet little movie from the 1980’s “I Heard the Mermaids Singing“? In it, there is a gorgeous opera aria that plays while the heroine flies through the sky. For years I’ve wondered what that aria was, and thought that I would love to learn to sing it.

Now I am no opera buff. I think I can recognize Madame Butterfly, and I know the movie Rent is based on La Boehme, but that’s about it. So it took me awhile to find out that this lovely aria is actually the Flower Duet from the opera Lakme’ by Delibe. (Click here to view it performed by Dessay and Maurus. Wait through the intro, the best part comes just after it…)

I bought the CD last month and have been listening to the song ever since. It’s actually a lovely opera, and I am enjoying more than just the Flower Duet. (I now have this image of myself really getting to know opera, and listening to the Opera at Lincoln Center on the radio while I cook on Sunday afternoons…)

The next step, of course, is to get the music, and convince someone to sing the other part of the Flower Duet with me. Any takers?

3. I Just Don’t Think I’ll Ever Get Over You (Colin Hay)

One of the best things about having your kids get to the teen years is that they bring new music into your life. And the great news is that there is some incredible new music out there.

Take a listen to this clip from Colin Hays album Going Somewhere, and tell me it doesn’t give you goosebumps…

4. Live at Blues Alley / Over the Rainbow- Eva Cassidy

Eva is one of the founding member of my Favorite Female Singers Taken Too Soon Club. (The other two members are Laurie Beechman and Nancy Lamott). I discovered Eva’s music some years back, only to find out that she had recently died from melanoma. Cruel, cruel world…

This album is her best, showing her incredible versatility and soul, as she moves from the jazzy Cheek to Cheek through a bluesy and smoky Stormy Monday to a rockin’ version of Take Me to the River.

But my favorite Eva Cassidy song is her beautifully unique rendition of Over the Rainbow on her Songbird album. Everytime I hear that song, it breaks my heart to think that she is gone. Click here to view a video of her singing this song. and here for a two part ABC segment on her life.

5. Enya (But not on purpose…)

I actually am not an Enya fan, and have never bought an Enya CD or listened to her voluntarily. When you call my friend Lori’s office and get put on hold, you can hear Enya. So sometimes I hear her then. But mostly, Enya wakes me up in the mornings.

You see, my neighbor, whose roof garden ajoins ours, waters her garden every morning at 6:30 am while listening to music. She seems to be particularly fond of our friend Enya over there. And so most mornings, Mr TBTAM and I, who sleep in our upstairs bedroom with the door open to our garden, are awakened to the sound of Enya’s singing.

And do you know what? It’s not a bad way to wake up. Except that while you are in that state between sleeping and dreaming, you start to wonder if maybe you died in your sleep and that the angels are singing…

Of course, now that the cool weather has arrived, Enya has taken to the indoors. Too bad – Now I have to listen to the damned alarm…

6. Nancy Lamott – Live at Tavern on the Green

As I mentioned before, Nancy Lamott is another member of my Favorite Female Singers Taken Too Soon Club. Nancy is one of the greatest cabaret singers of our time, not because she brings the house down with her voice (although she does), but because she epitomizes the intimacy, warmth and spirit of cabaret.

I was introduced to Nancy though one of my favorite radio programs, The Saturday Show with Jonathan Schwartz. I ran out to buy this album, fell in love with it, and then headed to the web where I learned that, tragically, Nancy had died from uterine cancer shortly after recording it.

A loss, to be sure, but I am thankful that we had her for the time that we did. Best song one the album? Hands down, Listen to My Heart.

7. Hallelujah – Rufus Wainright or Jeff Buckley?

Leonard Cohen wrote the song, but the definitive version belongs to Buckley. However, I really like Rufus’s version, recorded on the soundtrack of Shrek. His voice, the ease with which he sings, the piano instead of the guitar.

Here’s an amazing video of Buckley singing Hallelujah. Then check out Rufus doing his version on the Shrek Soundtrack, or in concert. You decide, I can’t.

And more…
This was very difficult for me, choosing just seven. I feel like I left so much out. So here’s a sample of what’s in my CD case (I don’t have an ipod yet…) Click on the links for the album. Enjoy!

Keith Jarret – Tokyo ’96 [Live]

Lyle Lovett and His Large Band

I am Sam Soundtrack

The Divine Miss Sarah Vaughan

Gillian Welch – Revival

Profile – The Best of Emmylou Harris

Norah Jones – Come Away with Me

Category: Considerations