Removing the Fallopian Tubes to Prevent Ovarian Cancer – Something to Consider

Uterus Tubes and OvariesNew information strongly suggests that most ovarian cancers originate, not in the ovary, but in the fallopian tube. If this is so, then removal of the fallopian tubes may actually prevent ovarian cancer.

The evidence is powerful enough that the American Congress of Obstetricians & Gynecologists is now recommending that fallopian tube removal be considered in women planning to undergo surgical sterilization or hysterectomy.

The Fallopian Tube Origin of Ovarian Cancer

We used to think that ovarian cancer originated in the peritoneal lining that covers the ovaries and abdominal organs. But the fallopian tube origin of ovarian cancer makes so much more sense when you consider what we know about ovarian cancer.

Think about it. The fallopian tube is an open tube that almost caresses the ovary at its distal end, where it is open to the abdominal cavity. Its blood supply is intimately shared with the ovary, and its inner surface is bathed in fluid that it shares with the fluid of the abdominal cavity. According to the theory, cancerous cells arise in the fallopian tube from small precancerous precursor lesions, where they grow undetected until they metastasize to the nearby ovary, or to the abdominal wall and surface of the pelvic and abdominal organs.

This goes a long way to explain why ovarian cancer is more often spread beyond the ovary to the pelvis and abdomen  (Stage 3) and not just confined to the ovary (Stages 1 and 2) at diagnosis.

It also helps to explain how ovarian cancer has stubbornly eluded our attempts at screening. Because by the time the ovary appears abnormal on ultrasound, the cancer has already spread beyond its primary site. (Fallopian tubes are not easily visualized on pelvic sonogram.)

Note that the type of ovarian cancer thought to originate in the fallopian tubes is the so-called “serous” ovarian cancer. Serous cancers account for about two-thirds of ovarian cancers.  The other third of ovarian cancers are endometriod and small cell cancers (which are thought to originate in the uterus or within the ovary), mucinous cancers (which may originate in the ovary or in the GI tract), and germ cell tumors (which originate from germ cells in the ovary).

What evidence is  there?

Data a rapidly accumulating to support the fallopian tube origin of ovarian cancer.  Here’s what we know so far –

  • In BRCA positive women at high risk for ovarian cancer, prophylactic removal of the tubes and ovaries finds hidden cancers in 7-15 % of women, but over half of these cancers are in the distal end of the tube, not the ovary.
  • The gene mutations found in serous ovarian cancers are the same ones found in the fallopian tube cancers, and the gene expression of serous ovarian cancer cells is more like that of a fallopian tube cell than an ovarian cell.
  • Scientists have found precursor lesions at the ends of the fallopian tube, that while not cancerous, look an awful lot like ovarian cancer cells.
  • Women who have had their tubes tied have 30% lower rates of ovarian cancer than those with intact tubes. The cancer prevented are the types (clear cell and endometriod) that would seem to originate in the uterus, based on the type of cells in the cancer.
  • Women who have their fallopian tubes removed have a 60% lower risk of ovarian cancer, and the type of cancer prevented are both the types that originate in the uterus and the type that we now think originates at the end of the fallopian tube nearest to the ovary (serous type).

So sign me up, already.

Not so fast.

As safe as it has become, surgery is not without risks.  Operating on every woman to prevent a cancer that few (1% or less) will get may not make sense.

But for women who are already planning to undergo surgery for hysterectomy or tubal sterilization, it is not unreasonable at this juncture to consider removing the tubes while you’re there. This will add little to the risks of the procedure already planned, and may have the potential benefit of preventing ovarian cancer.

What if I am at high risk for ovarian cancer?

At this point in time, the standard of care for prevention of ovarian cancer in BRCA carriers and others at high risk is prophylactic removal of both the tubes and ovaries, a procedure called bilateral salpingo-oophorectomy, or BSO.

But there are downsides to salpingo-oophorectomy for ovarian cancer prevention.  Even though the procedure is usually performed after completion of childbirth, it can cause early menopause, with its own risks of osteoporosis, heart disease and earlier death. If removal of the tubes proves to prevent ovarian cancer, this would be massively important for high risk women, who would have an option for ovarian cancer prevention that will NOT put them into menopause.

Large clinical trials are in progress to determine whether tubal removal will provide the same protection as BSO, but the results of these trials are years away.  If the 60% reduction found in the general population holds up, this may not be a good enough for high risk women, who currently get a 95% risk reduction from salpingo-oophorectomy.

There are reasons other than cancer protection to recommend tubal removal at the time of sterilization

Tubal sterilization is not perfect.

We now know from large longitudinal studies that failures occur more than you’d expect after sterilization, and range from a low of 3.8/1,000 for post partum tubals to as high as 54/1,000 for cautery (burning) of the tube. Failure rates from the Essure procedure are even higher – 96 per 1,000 – that’s almost 10%. Pregnancies that occur after these failed tubals are very likely to be life threatening ectopic pregnancies.

Renowned family planning researcher Mitchell Crenin, MD and colleagues argued persuasively in a recent editorial that the time for sterilization by tubal removal is long overdue. Moreover, if we gynecologists had included women in the discussion from the get go as we began to bandy about sterilization options, including Essure, most women would tell us they want the most effective procedure there is – which happens to be tubal removal.

The recent discoveries of a link between the Fallopian tube and ovarian cancer have brought this issue to the forefront; however, women have not been included in the discussion about their desires, specifically around pregnancy prevention. If failure (pregnancy) is considered a major morbidity, how much more complicated is a bilateral salpingectomy as compared with laparoscopic tubal interruption… the question should not be focused only on ovarian cancer prevention; rather, the more important question should be why we are not offering women a chance for near 100% efficacy by removing the Fallopian tube completely for sterilization.

I’d have to agree.

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More Reading

Image by CDC, Mysid [Public domain], via Wikimedia Commons

I’m Singing in The Events

The Events

I’m so excited to share that my chorus, the Collegiate Singers, will be singing on Feb 25, 2014  in the NY Theater Workshop production of David Greig’s play “The Events”, the play that won a First at the 2014 Edinburgh Fringe, and has been touring ever since.

 The Events tells the story of Claire—an enthusiastic and engaged female priest who leads a choir in a community setting. Claire experiences something terrible: a young man she vaguely knew turns a gun on those who “aren’t from here” in a misguided attempt to make his mark on society. The Events is not a depiction of such terrible events, and the play is not filled with violent acts. It follows Claire’s attempt to understand how someone could do such an awful thing, and how this struggle leads her on a path that comes close to self-destruction. Ultimately, Claire finds her peace and retakes her place in society as the play offers a timely exploration of how communities respond to acts of unthinkable transgression. (Wexarts.org)

Each night of the performance features a different community choir singing the soundscape of the play.

The use of a choir became a key aspect of “The Events,” and a way to root each production to the community wherever it is performed. In the show, a woman plays the role of Claire and a male actor plays several other parts, including the killer. The only other cast member, as it were, is an actual choir that functions like a Greek chorus, alternately observing, singing, chanting or speaking scripted line. (NYTimes)

Here’s a review from the NY times of the touring production in New Haven last year –  http://www.nytimes.com/2014/06/15/theater/david-greigs-the-events-is-coming-to-new-haven.html

I have absolutely no idea what this experience will be like, either on stage or as an audience member. But if you’re up for taking a chance, and you’d like to come to the play, you can get tickets here – http://nytw.org.http://nytw.org. http://nytw.org.http://nytw.org.

My chorus is performing only on Feb 25th, but the show runs Feb4-Mar 22.

Breast Screening Decisions – A Mammogram Decision Aid

bsdsite2

I’m proud and excited to introduce you to Breast Screening Decisions, an online Mammogram Decision Aid designed to provide individualized, unbiased information that can help women ages 40-49 decide when to start and how often to have screening mammograms.

Breast Screening Decisions (BSD) was created in the wake of the 2009 US Preventive Services Task Force recommendations that every woman in her 40’s make an individual decision about when to start and how often to have mammograms. Not all medical groups agreed with the USPSTF recommendation, adding to the confusion many women feel about the mammogram decision and putting providers in the difficult position of having to steer each patient through the controversy to a decision that feels right for her.

Breast Screening Decisions is a support tool for shared mammogram decision making between women and their health care providers. Women ages 40-49 can access BSD online at their own convenience, then bring in the BSD summary to a preventive care visit, where an informed discussion can occur, leading to a decision about screening mammograms that both patient and her provider can feel good about.

Breast Screening Decision is not designed to influence mammogram decisions, but to inform and reduce anxiety around the decision-making process for both women and their providers. We want to help women make the decision that is right for them, whatever that decision may be.

Who Should Use Breast Screening Decisions?  

  • Breast Screening Decisions is for women ages 40-49. Women outside this age group should not use the site, as the data presented will not apply to them
  • Breast screening Decisions is for women at low to average risk of breast cancer. BSD starts with a breast cancer risk assessment – a series of questions to help women find out their own breast cancer risk. Women at higher than average breast cancer risk based on personal or family history are then advised NOT to use BSD, but instead to speak to their doctor about which breast cancer screening modalities are best for them – usually annual mammogram, but sometimes with the addition of sonogram or breast MRI.

A Tour of Breast Screening Decisions

Breast Screening Decision starts with a breast cancer risk assessment – a series of questions to help women find out their own breast cancer risk, which is then shown to her visually –

BSD YOUR RISK

The user then sees possible mammogram screening outcomes for women such as herself –

mammo bsd

including information about both the benefits as well as possible harms of screening mammogram. BSD also includes lots more info on breast cancer and mammograms that women can access through pop ups and link outs.

The heart of BSD is the option array – where BSD users can scroll through the various screening options available to them, using a a grid which displays the breast cancer mortality outcomes for each possible mammogram screening schedule – every year vs every other year or starting at age 40 vs  starting at age 50. (I love this page of the website…)

bsd mortality

The user then is shown a summary page of their breast cancer risk and possible outcomes –

bsd summaryBSD concludes with a series of questions to help women clarify their concerns and personal values around breast cancer screening.

bsd values

And finally, BSD users are given a summary to save or print out, and bring to their appointment with their health care provider.

bsd summary

An Invitation

If you are a woman ages 40-49 or her provider, we invite you to use Breast Screening Decisions, and hope it will prove to be a valuable resource in making individualized decisions about mammograms.

We welcome collaborators interested in studying the effectiveness and impact of BSD in clinical practice. If you’re interested in collaborating with us, please contact us – Margaret Polaneczky, MD (mpolanec@med.cornell.edu) or Elena Elkin, PhD (elkine@mskcc.org).

The BSD Back Story

It all started in December 2009 with a blog post I wrote explaining the United States Preventive Services Task Force Recommendations on Screening Mammograms. I was as confused as my patients were about the recommendation that the decision as to when to start and how often to have screening mammograms be an individualized one that takes into account a woman’s risk for breast cancer, as well as her personal values and concerns about breast cancer and mammography.

How the heck was I going to accomplish that in a 15 minute office visit, let alone be confident that the choice my patients made was indeed an informed one? My knee jerk response was just to ignore the recommendations and tell everyone to get an annual mammogram, regardless of who they were or what they may have wanted to do. I would certainly be supported in that tactic by my own ACOG, as well as the National Cancer Institute and of course the American College of Radiology.  Not to mention, it’s the fastest way to get off a controversial topic in the midst of busy office hours and the safest choice medio-legally.

But as I wrote that blog post and started to wrap my head around the facts about mammography as we know them today, I began to understand why some women might make a choice different that I would be recommending. In fact, I already had more than a few women in their 40’s ask me if they could skip their annual mammograms – healthy, low risk women, with no family history of breast or breast-linked cancers, some of whom had already had one or more false positive mammograms.  They wanted to back off the annual screening, and they wanted my support.  I stumbled through an office counseling session, doing what I could to confirm their low risk status, and we usually ended up compromising on an every other year schedule, while I remained worried that I was setting myself up for a lawsuit.

This was not going to work long term – not for me or for my patients. They deserved my support in making this choice, and I deserved some support in making sure their choice was an informed one, and in supporting them when they chose an option other than annual screening.

The blog post I wrote on the topic had received so much positive press (The Washington Post called it the “clearest assessment of the controversy you’re likely to find”) that I knew I was onto something. So I approached Al Mushlin, Chair of Public Health at Weill Medical College where I work, and told him I wanted to build a web-based mammogram decision aid. He hooked me up with Elena Elkin, brilliant outcomes researcher at Memorial Sloan Kettering and grant writer extraordinaire. We (well mostly Elena) wrote a grant and got funding from the Cornell CTSC. And together with our amazing research coordinators Paige Nobles and Val Pocus (both of whom unexpectedly turned out to also be web-savvy, graphically-minded visual artists), with input from Al and from experts in mammography and breast cancer, along with feedback from beta users in our target population, we build the first version of BSD (Thank you, Marwan Shouery) and piloted it with over 150 women and their providers at the primary care and Ob-Gyn practices at Weill Cornell Medical Center. We hope to publish the results of our pilot study soon, but suffice it to say that BSD was well received by women and providers alike.

For reasons related to firewalls and such (lessons learned), we had to rebuild BSD from scratch for public access (Thank you, Mohammad Mansour and colleagues), and that is the site we are releasing today.  Other than some new colors, prettier formatting and a new font or two, BSD is the same site as the one we researched. The research site will remain behind a very tight firewall for use in future research.

So now..

Almost four years, many many hours of collaborative work and thousands of dollars later, Breast Screening Decisions is finally live to the public.  

Just in time for the next USPSTF update on mammogram screening …

 

A Call for Peace & Interfaith Dialog

Thanksgiving 1

Four Congregations, One Thanksgiving (from Trinity Wall St Blog)

Here’s an event you didn’t see covered in the media because it doesn’t make headlines or stoke the fires of hatred that seem to be flaring across this globe of ours.

It happened on Thanksgiving –

More than two hundred and fifty meals were served at Interfaith Community Thanksgiving in St. Paul’s Chapel on Thanksgiving Day November 27. The event was a joint effort of Trinity Wall Street; Park 51, an Islamic community center; Tamid: The Downtown Synagogue, which meets in St. Paul’s Chapel; and Lower Manhattan Community Church.

The Interfaith Group met again last week, and together its members designed and created the logo and button below as their mantra for an end to the divisive battles couched in religion that are driving a wedge between people of all faiths across the world.

The button’s logo is ambigious enough to invite questions and induce dialog. And that’s exactly what happened today when I saw Westina Matthews, a member of the Trinity Vestry, wearing her button. I asked, she shared their story and then gave me her button.

It Stops Now

The  Interfaith Group is doing more than stopping something. They’re starting something.

Something wonderful.

Calcium – Forget the Supplements. Get it in Your Diet.

MILK“How much calcium should I be taking?”

It’s a question I get several times a day from women of all ages, but mostly from those in the menopausal and peri-menopausal age group.

The answer I almost always give is – less than you think.

And for most women, probably none.

It’s not that I don’t think calcium is important

It is. Adequate calcium and vitamin D are critically important in building and maintaining a healthy bone mass.

But most women, with the exception of those who can’t tolerate dairy, are already getting a significant amount of calcium intake in their diet.  So much so that taking calcium supplements adds little to their overall health.

In fact, the US Preventive Services Task Force recently recommended against routine calcium and vitamin D supplementation in healthy post menopausal women.

What harm can a little extra calcium do me? 

More than you might think. Calcium supplementation can lead to –

  • Kidney stones Too much calcium can lead to kidney stones, a risk confirmed by the Women’s Health Initiative Calcium Study. In this study, women were given 1000mg a day of calcium plus 400 IU of vitamin D (regardless of vitamin or dietary intake) or a placebo.  Not surprisingly, there was a significant reduction in fractures in women over 70 who took their calcium as prescribed, but at the price of a 17% increase in kidney stones. For every 10,000 women taking calcium, there were two less hip fractures but 5 extra cases of kidney stones.
  • Constipation. Calcium can also cause constipation, so why take more than you need? (If constipation is a problem for you, try taking calcium with magnesium).
  • Interference with absorption of both iron and zinc.

You may also have heard that calcium supplementation can lead to heart disease.  It’s still an open question.  Some studies suggest up to a 20% increase in heart disease in men and women who take calcium supplementation. Other studies do not find this risk, or find it only in men and not women. In the Women’s Health Initiative study cited above, no increase in coronary calcium scores were seen in women who took 1000 mg of calcium daily, which is a reassuring result.

Calcium and other vitamins and mineral pills are called “Supplements” for a reason

They are meant to supplement, not replace, the primary source of calcium intake, which is food.  

So instead of taking supplements, get your calcium in your diet.

What About Vitamin D? 

Its a question without a good answer. The USPSTF recommendations only applies to Vitamin D doses under 400 IU.  We don’t know if higher doses of D are worthwhile or not, although the WHI study suggested they are beneficial when taken with calcium in preventing fractures in post menopausal women.

My Recommendation

Unless you’re at increased risk for fracture (You can calculate your fracture risk here), forgo the supplements and get your calcium from dietary sources.

If you don’t eat dairy, look to non-dairy calcium sources, and only take as much calcium supplementation as you need to make up the difference between dietary sources and the RDA for your age group.

I’m not adverse to vitamin D supplementation, but I recommend doses of 800IU daily.Dietary Sources Calcium

Chart from NIH Dietary Fact Sheet on Calcium

Additional Reading

A slightly different version of this post originally appeared on Web MD.

On Abortion, Jail, Parental Responsibility & Bad Judgement

scales abortion vs safetyJennifer Whalen, a 39 year old mother of three from rural Pennsylvania, is serving a 9-18 month jail sentence for purchasing and dispensing abortion-causing medications to help her teenage daughter abort an unplanned pregnancy.

The case is being used as an example of the lengths that women will go to to end a pregnancy when abortion is not immediately and freely available.

And perhaps it is.

But it’s also an example of just how easy we expect everything to be, and how those expectations are leading us to do things that are really, really stupid.

Because make no mistake. What Whalen did was stupid, irresponsible and dangerous.

Abortion is legal in Pennsylvania.

It was available to Whalen’s daughter with parental consent (which she clearly had) at a safe facility 75 miles away. That’s about an hour and 15 minute ride. Not the end of the world.

Yes, Pennsylvania has an absolutely ridiculous law requiring a 24 hour waiting period, meaning Whalen might have had to take time off from work to get her daughter an abortion. Or not – because the abortion facility nearest them has Saturday hours.

And yes, Whalen and her husband had just one car. And no health insurance for the $400 procedure.

I get it.

I really do. This was not going to be something easy.

But this is an abortion. A medical procedure that, while exceedingly safe, needs to be done by someone who knows what they are doing. Whalen, while not a licensed RN as previously reported, works in a healthcare facility as a nurses aide. So I’m sorry, but she should have known better. And I don’t quite buy it that she did not know that buying abortion pills online without a prescription was illegal.

And I won’t get into the ethical issues of aborting your daughter’s pregnancy, but it raises so many concerns about coersion that I know the docs at Geisinger Medical Center were right to report the case to the authorities after Whalen took her daughter to their ER during her induced miscarriage.

So, in case it’s not obvious by now…  

I’m not jumping on the “Poor Jennifer Whalen, she had no choice, she was ignorant, she was scammed by online sellers of abortion pills and sent up the river by those mean doctors in the ER” bandwagon.

Yes, I’m pro choice. Yes, I abhor the rash of abortion restrictions being passed by state legislatures across this country. And yes, I truly wish that abortion were freely available at every doctor’s office in every small community everywhere.

But it’s not.

And in this reality we have, parents like Jennifer Whalen have to make choices – to do the right thing, even when it’s the harder thing, or to do what’s easy.

She chose the easy route, and I think by now she knows that she made a bad judgement.

Now, do I think Whalen deserves a 6 month prison sentence? 

Of course not.

Whalen was not setting herself up as an abortion provider. She was not selling her services or posing as a health professional.

One time, she purchased medication over the internet for her daughter, who by all accounts took the medication freely and of her own accord. The medication, thankfully, worked as advertised.

But rather than come up with a way to turn this case into something positive for Whalen, her family and the community of women at large, Montour County DA Rebecca Warren and Judge Gary Norton chose instead to criminalize a mother for making the wrong choice in a very tough situation.

Warren says this case is not about Abortion Rights , but about “endangering the welfare of a child“.

Because sending a mother to prison is really good for her children, right?

Talk about bad judgement.

Putting Up Irene & Rita’s Fresh Summer Tomato Sauce

Ever since I first saw Mrs Frake putting up pickles and mincemeat in the movie State Fair, I’ve wanted to put up something.

As opposed to putting up with something, which basically describes my life.

I did once put up a few small jars of blackberry jam with the kids while vacationing on Block Island. We tried to sell the jam at the playground – I think someone bought one jar – then used the rest of the jars pretty much immediately. And that was the end of my putting up.

Until this week, when I was faced with forty pounds of South Jersey Roma tomatoes (Thanks Patty!) a few days after meeting blogger Marissa McClellan, who was selling her book Food in Jars at the Union Square Greenmarket and two days after my mother-in-law Irene sent me a recipe for what she is calling the best tomato sauce she’s ever made.

The stars had aligned. It was time for a real put up.

A Warning

First of all, I must warn you. This tomato sauce recipe has not been formally “tested” as safe for canning.  However, it is not dissimilar in amounts of olive oil, garlic and peppers to other recipes I found on the web that are tested for canning. Just to be safe, I’m freezing all but one jar of my canned sauce, and will update this post in 6 months or so when I open up the one unfrozen jar to see how it fared.

Of course, you don’t need to put up this sauce. You can just make it, use it and eat it right away.

A Second Warning

Forty pounds of tomatoes is a lot of tomatoes.  Unless you have a 3 day empty weekend, or are willing to give up three to four straight week nights (for me happily coinciding with Ken Burns’ The Roosevelts on PBS) and a bit of sleep, I do not recommend starting with such a large amount of tomatoes.  I spent an entire evening making 5 quarts of sauce, not to mention the clean up time, which left me getting to bed well after midnight and still with 20 pounds of tomatoes.

The next night I got smarter, I thought, and made oven dried tomatoes. (That post is coming up) The first batch was a disaster, and while the second batch turned out okay, I had to set the alarm to check the tomatoes every few hours overnight.  That left me with about 10 pounds of tomatoes. Those I will blanch, skin and can tonight.  Hopefully, it will go quickly.

How I canned this sauce

I canned my sauce using a water processing method. (This is as opposed to using a pressure canner.)

  • Make the sauce as directed, multiplying by 6 and using about 18 pounds of tomatoes.
  • Towards the end of the vegetable roast, fill a large stockpot with water, place a 12 inch metal cake cooling rack on the bottom, then fill and submerge 5 one quart mason jars in the water. (Your jars should not sit directly on the bottom of the pot – you can put a dish towel there if you don’t have a rack or a trivet to use).
  • Boil with the lid on for 10 minutes (My stock pot lid has a steam scape valve – very handy), then turn it down on a very low heat to keep the jars warm so that they will not break when I you add the hot sauce.
  • Boil the lids in small saucepan and turn them down to keep as well.
  • After the sauce is made, and has simmered for 10 mins or so as directed, remove the mason jars from the water bath with a pair of tongs (I need to get a jar lifter for future efforts, this was a bit precarious). Fill the jar, wiping away any excess sauce near the top and leaving 1/2 -1 inch airspace, then put on the lids and finger-tighten them.
  • Return the now-filled jars to the stock pot, sitting them neatly on the submerged cake racker and removing the excess water from the pot with a small sauce pan, so that the final water level is 1-2 inches above the top of the jars. (Since the jars are now filled, you don’t need as much water in the pot.) I was able to fit 5 quart jars in my large stock pot.
  • Bring the water to a rolling boil, cover the pot and let it boil for 45 minutes. (This is an extra ten minutes over the recommended processing time for quart jars at sea level, but I wanted to be  safe. Processing times do vary by elevation – you can check here for the right time for your location).
  • After processing, I remove the jars to a towel-covered counter top and let them sit and cool overnight. As mine cooled, I could hear the lids popping (a good sign that the vacuum seal has worked).  Although some folks say to remove the outer rings and just let the cans sit with the vacuumed lids atop, I’m leaving the rings on.

Bottom Line

Putting up is fun, but laborious. It’s not an undertaking to be taken lightly, and you must be sure to do it safely. I learned a lot this first go round.  Stay tuned for more next season.

RITA & IRENE’S FRESH SUMMER TOMATO SAUCE

Irene&Rita's Tomato Sauce

This recipe comes from my mother-in-law Irene, the world’s greatest home cook, via this delightful email she sent to me a few weeks ago-

Hi Peggy,  Here it is 10am Sunday morning and I just finished making the best tomato sauce I ever made.  I was sitting in the dentist’s chair on Thursday going through 2-1/2 hours of dental fun.  The dental assistant, Rita and I were having some delightful conversations about food.  She’s a vegetarian and we had a lot to talk about when I didn’t have a lot of stuff going on in my mouth.  At one point she told me of a fresh tomato sauce she makes that’s very good.  All she gave me were the basic ingredients, without amounts,  the oven temperature and the time —tomatoes, red pepper, garlic, olive oil, 350 oven for an hour and a half.  I had to figure out how to do it and season it.  Here’s what I came up with.

This recipe is for one batch of sauce. I multiplied the recipe by 6, using about 20 pounds of tomatoes, and got 5 quarts of sauce.

  • 5 large summer tomatoes, quartered (or 3-4 pounds roma tomatoes, halved)
  • 1 large red pepper, seeded and cut in 1/6ths
  • 1 bulb of garlic, unpeeled (that’s a bulb, not a clove)
  • 2 tsps. sea salt
  • lots of freshly ground black pepper
  • 1 tsp. sugar
  • 1/4 cup olive oil

Do not peel the tomatoes, the pepper or the garlic, the skins come off easily when they’re finished roasting.  Place all ingredients in a large roasting pan. Place in 350 oven for 1-1/2 hours.

Remove from oven and let cool for about a half hour until the tomatoes and pepper and garlic are cool enough to handle and peel. Peel the tomatoes and peppers into a large sauce pot, discarding the skins. Squeeze the roast garlic into the pot and discard the skins. Using an immersion blender, blend tomatoes, peppers and garlic to a smooth sauce. Add back the oil and juices from the pan as needed to thin the sauce to the right consistency (I used about 3/4 of it). Heat to boiling and then simmer 10 mins.  Season as necessary.

Use immediately, or pour into prepared canning jars and process.

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Some great links on canning

The Music of The Children Act

Music features prominently in Ian McEwan’s new book The Children Act. The book’s protagonist Fiona Mayes, a family court judge, is also an accomplished pianist, and both she and her husband Jack are lovers of jazz.  Almost every important moment in the book, aside from the first scene and Fiona’s time in the courtroom, occurs while music is being played or listened to.

I love how McEwan weaves the musical themes seamlessly throughout the story, informing character, time and place. I listened to the Audible book (a fabulous performance by Linsday Duncan), and found myself wishing that someone had thought to add a score to the recording.

For those of you reading the Children Act and also wondering what it might sound like, here are some recordings and a little context from the novel.

Bach’s Second Partita in C Minor for Keyboard

I loved this passage, as Fiona walks to work, trying to distract her thoughts from her failing marriage by recalling the Bach Partita, a distraction that of course, fails.

Children.

The inevitable thought recurred as she moved on to the demanding fugue she had mastered, for love of her husband, and played at full tilt, without fumbling, without failing to separate the voices. Yes, her childlessness was a fugue it itself. A flight. This was the habitual theme she was trying now to resist. A flight from her proper destiny. A failure to become a woman, as her mother understood the term.

How she arrived at her state was a slow patterned counterpoint, played out with Jack over two decades, dissonances appearing then retreating, always reintroduced by her in moments of alarm, even horror, as the fertile years slipped by, until they were gone, and she was almost too busy to notice.

Down by the Sally Gardens

Fiona visits a young man with leukemia in the hospital as she tries to decide if the court will force him, a Jehovah Witness, to take blood products that will save his life.  In a very non-judicial moment, as he plays Down by the Sully Gardens on his violin, she sings along. That moment and that song decide the case for her, sealing his fate and binding them together in a way she had never anticipated.

Keith Jarret – Facing You – (First track) In Front

Jarrett ‘s Facing You was “one of three or four albums that formed the soundtrack” of Fiona and Jack’s early relationship. Jack now uses the album to begin to bring them back together.

..the technical facility, the effortless outpouring of lyrical invention as copious as Mozart’s, and here it was again after so many years, still holding her to the spot, reminding her of who she and Jack once playfully were.

Hector Berlioz: Les Nuitsd’ete – Villanelle  / Gustav Mahler Ich bin der Welt abhanden gekommen (I Am Lost to the World)

The book culminates in a live performance by Fiona and a tenor colleague, a performance that coincides with her learning of the fate of the young boy. The combination of such beauty and such sadness in the two pieces they perform mirror the young man perfectly.

I have become lost to the world, where I used to waste so much time;
It has been so long since it heard from me, that it may well think that I have died!
I don’t care if it thinks me dead, for I really have died to the world.
I have died to all the world’s turmoil, and I rest in a silent realm.
I live in solitude in my heaven, In my love, in my song.

Patient Identifiers, Hospitals & the EHR

FIngerprintCurrent Joint Commission standards call for the use of two patient identifiers to avoid mixing up patients with the same or similar names. For inpatients, these identifiers are usually the name and the medical record number (MRN).

Which is fine if the only place you need to identify the patient is your own hospital.

But your hospital’s MRN is meaningless to me and my EHR.

So if you send me a copy of my patient’s chart (or her lab result or mammogram report) and all that’s listed on the top of the page is her very common name and your MRN, I have no clue who this patient is.

(My EHR gives me a box to check to confine the search to my own patients, but that button only works about 10% of the time.)

So please, hospitals, start adding the patient’s date of birth to your printed reports and records.  And EHR vendors, you could make it easier for all of us by defaulting to a header that includes the date of birth as an identifier.

Thank you.

 

The Not So Scary Truth About HPV

http://www.dreamstime.com/stock-images-emotion-2-image597604There’s a downside, I think, to educating the public about the link between HPV infection and cervical cancer.  And that’s scaring the bejesus out of every woman who happens to find out she has HPV.

It’s not surprising that you’re scared.

You see, we want you to know that HPV infection is linked to cervical cancer, and that we have a vaccine against HPV that can prevent cervical cancer. So we’ve been doing our best to get the word out. (With no small bit of help from the HPV test and vaccine manufacturers.)

But in our zeal to get you screened and vaccinated, we sort of forgot to tell you something equally important. And that something is this –

Pretty much everyone – 80% of US adults- will get HPV at least once, if not more than once, in their lifetime. At any given time, 20-30% of US women ages 14-59 have HPV. That’s right – a third of the female population. If you include men, there are about 20 million persons at any given time in the US who have HPV.

The overwhelming majority of HPV infections do NOT lead to cervical cancer. Around 95% of the time, the infection clears, usually within 1-2 years, without you, or anyone, doing anything

Yes, the problem with HPV disease awareness is that it ultimately makes every woman feel like she have a bull’s eye on her cervix. Which may a good way to get her in for HPV testing and vaccination, but is actually misleading women about an infection that basically everyone gets at some point in their lives.

The Not So Scary Truth About HPV

The truth is that while having HPV is a necessary precondition for getting cervical cancer, it’s also true that almost all HPV infections DO NOT lead to cancer

Think of it this way. Getting in a car is a necessary condition for having an automobile accident, but in fact, most of us will make it to our destination alive. Same thing with HPV. The chain of events that ultimately leads to cervical cancer starts with HPV infection, but almost all the time something intervenes to prevent cancer. That something is called your immune system.

If for some reason, your immune systems doesn’t do the job, and you’re in the 5% of women with HPV who don’t clear the infection, we have ways to monitor you closely so that if a precancerous lesion arises, we can treat it. Years before it becomes cancer.

But I have “High Risk” HPV 

So does everyone else with a positive HPV test.

“High risk” HPV subtypes are called that simply to distinguish them from the “low risk” types that cause genital warts.  Current HPV tests only screen for the “high-risk” types. So by definition, if you’re HPV positive, you have a “high risk” strain. (Someone really needs to change the name of that test…)

But if everyone has HPV, and most infections clear without treatment, then why do we test for it? 

HPV testing is better at finding precancerous lesions that Pap smear alone, so what the Pap misses, the HPV test will find. It’s so good that it’s being considered as a replacement for the pap smear as the first line test for cervical cancer screening.

The HPV test is also good for weeding out the false positive Pap smears. A mildly abnormal pap (ASCUS) can be safely ignored and repeated in a year if the HPV test is negative. This saves a lot of women unnecessary testing.

The other good thing about HPV testing is that if it’s negative, you’re really in the clear. So much so that if both the Pap and HPV test are normal, the risk for cervical cancer plummets, and you can safely wait up to 5 years between pap smears.

The problem with HPV Testing

The problem with HPV testing is that it has a very high false positive rate. Most of the women with HPV  actually do not have precancerous lesions. They just have HPV.

That’s what happened to NYC Councilwoman Melissa Mark-Viverito, who then went public with her HPV diagnosis on Twitter. Ultimately, when she had additional testing after her HPV diagnosis, she found out that she was fine.

Of course, you don’t want to ignore the fact that you have HPV.

You should take it as a sign that you, of all people, need to get your pap smears regularly. Or , if your doctor recommends it, have a simple office procedure called a colposcopy – a magnifying lens that looks for tiny abnormalities on the cervix that are too small to be seen by the naked eye, but if found, can be treated so that you never get cervical cancer.

But know that it would be exceedingly unusual for you to actually have cervical cancer just because your HPV test is positive. This is about finding precancerous lesions, and ultimately, preventing cancer.

So if you have HPV, don’t be scared. But be smart.

If you have HPV, odds are overwhelming that you’re going to be fine.  Between the HPV test and the pap smear, if you have anything precancerous, we’ll find it and we’ll treat it. Years before it becomes cervical cancer.

In the meantime, there are things you can do to help your immune system along. Things like not smoking, using condoms, getting enough sleep and getting 4-6 servings of fruits and veggies each day. Women who do these things clear the virus faster, although ultimately most will clear it anyway.

So do be smart and get screened. And follow through on whatever testing is recommended based on that result.

But please. Don’t be scared.

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More good info on HPV and cervical cancer.

A slightly modified version of this post first appeared on WebMD.

Corn, Zucchini and Chickpea Fritters

Fritters corn zucchini chickpea
Our first dinner in the empty nest.

We dropped our youngest off at college, which to our delight is a mere two hours drive north along the lovely Taconic Parkway. To say the campus is bucolic is an understatement, with the Catskill mountains on the horizon, and a lovely little town just a short ride away.  This was a happy day for us all, the culmination of an amazing summer for the entire family. She’s launched and we’re so happy for her. (And can’t wait to come back up to visit on parent’s weekend…)

After settling her in, we explore the area, following dead end roads like fingers that end at the Hudson River. We stop at an amazing little farm stand, where we find fresh corn and heirloom tomatoes.

Heirloom tomatoes

A little further down the road, the guy who owns the pastry store is selling huge zucchini from his garden at a little table out front of his shop. Of course we have to buy one.

At home later that evening, we find a recipe to combine our farm finds, and eat delicious vegetable fritters al fresco on one of the warmer days of this unseasonably cool summer, sitting on the terrace at the table which until now was too small for a family dinner. Now with just the two of us, it’s just the right size.

We share a beer and talk about the future.  Yes we miss the kids, but then we think of each of them – one settling in at her new college, the other launching a theater career (and a play opening!) in our hometown -and we are just so happy for them that we would not have it any other way.

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CORN, CHICKPEA AND ZUCCHINI FRITTERSfritters cooking

This is my own modification of a recipe from The Wednesday Chef, who herself modified a recipe from Taste.com/Au. Feel free to change up the herbs you use. Makes 12 fritters. If that’s too many fritters for one meal, the leftovers heat up nicely for lunch the following day. My mother in law Irene, who made these a few days after we did, instead froze the extra batter to make another day.

  • 1 15-oz can of chickpeas, drained & rinsed
  • 1/2 cup milk
  • 2 eggs
  • 3/4 cup flour
  • 1/2 tsp baking powder
  • 1 tsp salt
  • 1 large zucchini, grate
  • 2 large ears of corn kernels (about 2 cups)
  • 2 tablespoons chopped fresh mint leaves
  • 3 scallions, thinly sliced
  • Zest of one lemon
  • Canola Oil
  • Plain sheep’s yogurt and hot sauce for serving

Process chickpeas until roughly chopped.

Whisk milk and eggs in a measuring cup. Mix flour, baking powder and salt in a bowl. Gradually add milk mixture to flour, whisking until smooth. Stir in chickpeas, zucchini, corn, mint, scallions and lemon zest.

Heat a shallow layer of canola oil in a large skillet over moderately high heat. Add 1/4 cup mixture to pan. Spread slightly with a spatula. Repeat to make 3 more fritters. Cook for 2 to 3 minutes each side or until golden and cooked through. Transfer to a plate and cover or keep warm in a 200 degree oven. Repeat with remaining mixture to make 12 fritters. Serve with freshly sliced heirloom tomatoes, a dollop of sheep’s milk yogurt and a splash of hot sauce.

I’m Writing for WebMD

http://www.dreamstime.com/stock-photography-typewriter-keys-image14524512

I’m now writing for WebMD. Just one to two blog posts a month.

Here’s my first post.

It’s kind of exciting to actually be paid to write, although I don’t think I’ll be quitting my day job anytime soon.

I’ll be cross posting the Web MD posts here a week later, so you can read me here or there, and nothing will be lost from this blog.  (It is, after all, my baby.)

Let’s see where this thing goes…

Appetizers for Summer Book Club

Book Club appetizers

As much as I love book club, I love hosting it even more. Because hosting means I get to leave work early and do my favorite thing in the whole world – spend the late afternoon in my kitchen. I’m rarely at home at that time of day, when something wonderful happens to the light in our apartment as the sun begins to peek out from behind the tall apartment towers just south of us, and pours into my kitchen.  Add in NPR or a good book on tape and I’m in heaven.

The evening promised good weather, so we planned to meet on the roof.  I took my cue for the menu from the book we were discussing – “My Brilliant Friend”, set in Naples – and went for a Mediterranean theme. (Plus I had a whole mess of amazing, pitted Castelvetanos olives and a jar of fig preserves.)

In an amazing feat of pre-planning, something highly unusual for me, I actually decided on the menu and bought all my ingredients the day before, so I was able to head straight home and got to work around 4 pm. Luckily, Mr TBTAM was home early as well, and I put him to work weeding the rooftop garden, which we had ignored for most of the summer.  Somehow I managed to pull it all together by the time the group arrived at 6:30, with a little help from my friends who arrived first.

The discussion was as always, interesting and spirited, and we went till dark. This is one great bunch of women, and I’m thrilled to be a part of the group.

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Book Club Appetizer Menu

  • Fig & Blue Cheese Savories
  • Olive all’Ascolana
  • Manchego cheese with Firehook Za’Atar flatbreads
  • Nectarine segments and dried apricots
  • Wine; Mint lemonade
  • Cappucino almonds (Thanks, Amy!)
  • Sunflowers for the table (Thanks Stacy!)

Fig and Blue Cheese Savories

FIG AND BLUE CHEESE SAVORIES

These delicious babies come from The Runaway Spoon, found via Food 52.  I used a wonderfully pungent Roquefort style sheep cheese (Ewe’s Blue) from Nancy & Tom Clark’s Old Chatham Sheepherding Company.  I did not have a one inch round cookie cutter, so I used a floured 1 inch soda bottle cap. You may be tempted to make these bigger, but do not. The small size is perfect. They can be made ahead and kept in layers separated by waxed paper. They freeze beautifully.

  • 1 cup flour
  • 1/2 cup butter, room temperature, cut into four pieces
  • 4 ounces blue cheese, cut into several chunks
  • Ground black pepper
  • Fig preserves (about 1/4 cup total)

Preheat the oven to 350 degrees. Line a baking sheet with parchment paper. Process the butter, blue cheese, flour and a few grinds of black pepper in the food processor until the dough starts to form a ball. Dump onto a lightly floured surface, knead a few times to pull the dough together and roll out to 1/8 inch thick with a floured rolling pin. Cut rounds out of the dough with a floured 1-inch cutter and transfer to the parchment-lined baking sheet. Using the back of a round half-teaspoon measure or your knuckle, make an indentation in the top of each dough round. Spoon about ¼ teaspoon of fig preserves into each indentation. Bake the savories for 10 – 14 minutes, until the preserves are bubbling and the pastry is light golden on the bottom. Let cool on the baking sheet for at least 10 minutes, the remove to a wire rack to cool.

Can be made ahead or frozen in an airtight container in layers separated by waxed paper.

Olive all'Ascolana

OLIVE ALL’ASCOLANA  – Vegetarian Version

This recipe comes from Arielle Clementine via Food 52. It’s inspired by the classic Italian stuffed olives, which have a spicy meat stuffing and use olives from the Ascoli region of Italy. (Here’s a wonderful video on how to make the real thing, which I must try one of these days.)  I made some fresh breadcrumbs for this recipe, but did not toast the crumbs as I usually do, since they would get crisped as they fried. I had no mustard seeds, so used a pinch of dried mustard instead.  I fried them in my electric fryer, a kitchen appliance I only use otherwise for latkes, and it worked beautifully.

  • 24 large green olives, pitted
  • 1/2 cup goat cheese
  • 1 teaspoon whole mustard seeds
  • 1 teaspoon fresh rosemary, chopped fine
  • 1/4 teaspoon crushed red pepper flakes
  • 1 garlic clove, minced
  • 1 cup all purpose flour
  • 1 egg, beaten
  • 1 cup breadcrumbs (fresh or panko)
  • 1/3 cup freshly grated Parmesan cheese
  • 1 cup vegetable oil (I used canola oil)
  • parmigiano reggiano, for sprinkling
  • zest and juice from one lemon, for sprinkling

Mix the goat cheese, mustard seed, rosemary, chile flakes, and garlic in a small bowl. Stuff the olives with the cheese mixture (I used my fingers, rolling the filling like a small cigar and sliding it into the pitted olive.) Put the stuffed olives on a plate and refrigerate for 20 minutes. While the olives are chilling, heat the oil in a heavy-bottomed frying pan to 375 degrees. Set up three plates for your breading station (Flour, beaten egg, breadcrumbs+grated Parmesan) When the olives have chilled, roll half of them in the flour, then in the egg, then in the bread crumb/Parmesan and carefully drop them into the heated oil. Fry until golden brown, about one minute per side. Transfer to a plate lined with paper towels to drain, and repeat with the remaining olives. Pile on a plate and finish with a shower of freshly grated cheese and lemon zest and a spritz of lemon.

The Hobby Lobby Solution to Teen Pregnancy

Via Paul Rudnick at the New Yorker –

When it comes to the Court’s decision on contraception, I think I can be of service. For my five beautiful daughters, and the other one, I have used a cheerful heavy-gauge yarn, mixing strands of cashmere, alpaca, and barbed wire, to knit what I call a Crotch Cozy. When my girls wear their Crotch Cozies, they not only receive endless compliments in the locker room but sexual intercourse becomes impossible. Any additional form of birth control is unnecessary. Case closed!

A very funny read.

Unfortunately, there’s not much else funny about the Hobby Lobby. Read Jan Gunter, MD if you have any questions as to why its a bad ruling, not just for women, and not just for contraception.

The Berlin Wall in New York City

Berlin Wall in NYC
Meeting friends for dinner last evening at Valbella, I was surprised to discover that the strikingly painted concrete slab on display in the tiny plaza outside the restaurant is actually a section of the Berlin Wall.

That’s right. The Berlin Wall. Tucked away in a lovely little plaza on the north side of E 53rd between 5th and Madison. How could I have lived in NYC for over 20 years and not known it was there?

Berlin Wall in NYC
This section of the wall was illegally painted in the 1980’s by Berlin street artists Therry Noire and Kiddy Citny. Noire, who lived a mere 5 meters from the west side of the Wall, was the first street artist to paint on the wall, a risky act of political rebellion that he and the other street artists he inspired continued until the Wall came down in 1989.

To paint the Berlin wall, to transform it, to make it ridiculous, to help to destroy it.

– Therry Noire

Amazingly, the sections of wall on display at 520 Madison are the very ones Noire is painting in the  1987 Wem Wenders Film “Wings of Desire”.


After the wall came down in 1989, the East German Government, seeing the value in the art Noire and his fellow artists had created, ultimately auctioned off huge sections of the wall in Monaco, which is probably where Jerry Speyer of Tishman and Speyer, the owners of the plaza at 520 Madison, purchased this piece of history in 1990.

The artists who painted the Wall have seen very little of the income from the sale of the sections that bear their paintings, and it is not known where the profits from their sale, supposedly slated for humanitarian causes by the East German government, ultimatley ended up.

Kudos to Speyer for sharing his piece of the Wall with the public in this lovely little respite in midtown.

I encourage you to visit the Wall. If you choose to eat al fresco at Valbella, as we did on this warm summer evening, you’ll have plenty of time to  consider this infamous piece of history and the spirit of courage and freedom that both its demolition and the remarkable artwork painted on it represent.

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MORE READING

Berlinermauer The Berlin Wall (from Wikipedia)