After Breast Cancer, Get a Gym Membership!

Earlier this month the Journal of the American Medical Association (JAMA) published a myth-busting paper on weight lifting for women at risk for lymphedema after breast cancer treatment.  The study was neither large (154 patients at max, whittled down to 134 at analysis) nor high-tech (interventions involved gym memberships, weight training and lifting in neighborhood facilities like YMCAs).

The results were clear: working out with hand-held weights, carefully, is good for most women who’ve had surgery for breast cancer (BC).

Lymphedema, or swelling due to a damaged gland, can develop in a patient’s arm after removal of lymph nodes in the armpit. The uncomfortable condition can be disabling by impairing arm or hand movements. It affects a significant number of BC patients: among women who’ve had have just a sentinel lymph node removed, lymphedema affects roughly 6%; for those who’ve had complete axillary (armpit) lymph node dissection, the incidence is around 30%. There are roughly 2.5 million women living in the U.S. after a breast cancer diagnosis; most are at elevated risk for lymphedema.

Years ago, doctors commonly advised patients not to lift weights or perform strenuous exercises with their arms after a mastectomy or lumpectomy with lymph node dissection. To a lesser extent, this happens still today. As reported in the JAMA article:

Breast cancer survivors at risk for lymphedema alter activity, limit activity, or both from fear and uncertainty about their personal risk level, and upon guidance advising them to avoid lifting children, heavy bags, or other objects with the at-risk arm.9,10 Such guidance that deconditions the arm, increasing the potential for injury, overuse, and, ironically, lymphedema onset.11 Adherence to these precautions may limit physical recovery after breast cancer and, for some women, result in lost employment. Furthermore, activity avoidance may deter survivors from performing regular exercise…

The researchers recruited women in the Philadelphia area who’d undergone surgery for localized, unilateral breast cancer sometime between 1 and 5 years before the study. Each had at least 2 lymph nodes removed in surgery. The median age was around 55 years. The women were divided into two balanced groups before randomization – they received a year’s membership at a gym and a trainer for the first 13 weeks, or not.

So it’s good news that the women in “weight lifting intervention” group developed less lymphedema. What’s more, those women became stronger and sported a lower percentage of body fat. All of these differences were statistically meaningful and, for the most part, quite strong. Perhaps more remarkably, in a pre-planned subset analysis of women who’d had 5 or more lymph nodes removed, the proportion who experienced lymphedema in the weight-lifting group was only 7%, compared with 22% in the controls. That difference was highly significant, with a p-value of 0.003. The findings, in sum, show that it’s safe for women who’ve had breast cancer surgery to work out in a way that includes a careful, progressive upper body strengthening.

About a week ago, I was alerted to this article by Dr. Ramona Bates, a plastic surgeon who authors Suture for a Living. She’s had several recent, excellent pieces on this subject including a post on lymphedema and the JAMA report. I chose to write on this, in part, because it meshes with my professional and medical history.

In my case, I got conflicting advice on the matter. I wanted to continue swimming because it helps my scoliotic back. But some colleagues suggested that arm-intense strokes might be best avoided after mastectomies. A cosmetic surgeon rightly told me that some strokes might have untoward effects on implants. So I relied on my judgment: I chose to swim because it made me feel better and stronger. In the past year, I’ve started lifting a few small weights, carefully and slowly.

In the end, this is a story of a small clinical trial and the value of common sense in medicine. Weight lifting is not only safe; it can reduce the incidence of lymphedema in women at risk. But “old wives’ tales” still persist in some doctors’ minds; these need be dispelled. Finally, I can’t help but wonder what would happen if every woman could have a year’s membership at a local gym –


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First Inspection of Google’s Anatomy

Google Woman (Body Browser, clad)

This morning I toured Google’s new Body Browser. The trip wasn’t as easy as I’d envisioned; I got sidetracked on my way, having to update my Web browser before entering. The site requires an advanced Web browser, like Chrome beta or Firefox 4.0, to accommodate 3-D graphics.

Update accomplished, I forged into Google-woman’s frame. (There is no man available, as yet.)

muscles, frontal view

The muscles appear well-defined, though I’m no orthopedist. The platform reveals the piriformis, an obscure muscle beneath the glutes for which a physical therapist once gave me strengthening exercises. I could see the psoas major, which I’d learned years ago to check for tenderness by examining the abdomen while moving a patient’s hip in a specific manner.

The bones could definitely use some work. The 5 lumbar vertebrae should be numbered, as might be the 12 thoracic and 7 cervical elements of the spine, to name a few among many missing details in the skeleton. At various points the woman’s blood vessel system, or circulation, mixes in with her peripheral nerves. The brain findings are surprisingly limited. (all accessed 12/29/10)

This version of Google’s Body Browser remains in lab mode, for good reason. Still, it’s pretty amazing – you can twist and turn the human’s body, peel away layers and isolate nerves of interest. Knowing some anatomy and terms, I honed right in on the woman’s trigeminal nerve, choosing an oblique and semi-transparent view of her neck and head.

piriformis muscle, found

I think the potential for this Web-tool is huge. Doctors could learn with it. And although some of my colleagues might mind my saying so, this sort of platform might eliminate or at least reduce the need for so many cadavers for medical school education. As for providing patients with understandable information, this has tremendous value. Imagine sitting in a physician’s office with a computer screen as she points to a joint that needs repair, in real-time and 3-D, or explains the risks of prostate surgery, due to the nerves and other structures that run through or nearby that particular gland.

trigeminal nerve, revealed

Google’s developers have a lot of work ahead on this project. Like Google Maps, this should allow people to see things that will help them make sound decisions. We’re not quite there yet, but close.

For now it’s fun to look click through Google’s anatomy. It’ll be interesting to see how this terrific application progresses.


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Return from Charleston

Dear Readers,

A few days ago I traveled with my family to Charleston, South Carolina. It was my first time in that peninsular city. The place is a hotbed of tourism – stuffed with establishments of fine cuisine, art galleries and architectural landmarks.

Church Street, Charleston NC

We enjoyed the visit. I swam laps daily. I brushed up on U.S. Revolutionary and Civil War history. I made a serious dent in a book I’m reading about Cleopatra.

What I missed was the Internet, from which I was unintentionally disconnected for a few days. Surely some might think, or even tell me directly, that a digital break is a good thing. It’s healthy to step away from it, for sure. But it didn’t feel that way –

I enjoy these bits of writing. I’m glad to be back at home, and on-line.

– ES

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The Grinch That Almost Stole Christmas

Regular readers of this blog know that I’m not into rants. Complaining is rarely constructive, I know. But I spent the afternoon sorting through a 2-month stack of medical bills and correspondences related to those. Despite the fact that I consistently pay bills on time, we received threatening notices from local hospitals for payments they deemed late.

Three instances of avoidable hassle:

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The U-Shaped Curve of Happiness

This evening, when I finished cleaning up the kitchen after our family dinner, I glanced at the current issue of the Economist. The cover features this headline: the Joy of Growing Old (or why life begins at 46). It’s a light read, as this so-influential magazine goes, but nice to contemplate if you’re, say, 50 years old and wondering about the future.

The article’s thesis is this: Although as people move towards old age they lose things they treasure—vitality, mental sharpness and looks – they also gain what people spend their lives pursuing: happiness.

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Science Takes a Double Hit in the Press, Maybe

In his latest New Yorker piece The Truth Wears Off, Jonah Lehrer directs our attention to the lack of reproducibility of results in scientific research. The problem is pervasive, he says:

…now all sorts of well-established, multiply confirmed finding have started to look increasingly uncertain. It’s as if our facts were losing their truth: claims that have been enshrined in textbooks are suddenly unprovable. This phenomenon  doesn’t yet have an official name, but it’s occurring across a wide range of fields, from psychology to ecology. In the field of medicine, the phenomenon seems extremely widespread…

The Decline Effect, as Lehrer calls it, refers to scientists’ inability to reproduce reported results. The problem isn’t simple: it’s not just that different investigators or teams come up with conflicting information, or interpret the same raw data in disparate ways; over time, a single scientist may not be able to reproduce his or her own observations.

Lehrer begin his story with a target loaded with potential bias and conflicts of interest – a 2007 meeting in Brussels of scientists, shrinks and pharma executives contemplating the disappointing results in recent large clinical trials of blockbuster antipsychotic drugs like Abilify, Seroquel and Zyprexa. Initial reports, mainly from the early 1990s, which supported these drugs’ FDA approval and widespread use, turned out to present a too-positive story. Later studies indicate these agents are not as terrific as was advertised; new data call into question the drugs’ effectiveness and safety.

This is probably true, but it’s hardly surprising. It happens in oncology all the time – when drug companies support initial studies of new drugs with an intention to sell those, it’s sometimes the case (and unfortunately frequent) that initial reports are more promising than what really happens after a decades’ worth of less careful (i.e. more open) selection of patients who take an FDA-approved medication. Once you include a broader group of patients in the analysis, whose doctors aren’t researchers whose salaries are supported by the drug makers, the likelihood of getting truthful reports of side effects and effectiveness shoots up.

So I don’t think Lehrer’s big-pharma example is a reasonable shot at the scientific method, per se. Rather, it’s a valid perspective on problems that arise when drug companies sponsor what’s supposed to be objective, scientific research.

Lehrer moves on to what might be purer example of the decline effect. He tells the story of Professor Jonathan Schooler, a now-tenured professor who discovered in the 1980s that humans’ memories are strengthened by the act of describing them. The work is cited often, Lehrer says.

…But while Schooler was publishing these results in highly reputable journals, a secret worry gnawed at him: it was proving difficult to replicate his earlier findings. ‘I’d often still see an effect, but the effect just wouldn’t be as strong.’

Next, Lehrer steps back in history. He relates the story of Joseph Banks Rhine, a psychologist at Duke who in the early 1930s developed an interest in the possibility of extrasensory perception. (Yes, that would be ESP.) Rhine devised experiments to evaluate individuals’ capacity to guess which symbol-bearing cards might be drawn from a deck, before they’re drawn. The initial findings were uncanny: “Rhine documented these stunning results in his notebook and prepared several papers for publication. But then, just as he began to believe in the possibility of extrasensory perception, the student lost his spooky talent…”

Schooler, plagued with self-doubt about his published findings on human memory, as Lehrer tells it, embarked on an “ironic” attempt to replicate Rhine’s work on ESP. In 2004, he set up experiments in which he flashed images and asked a subject to identify those; next he randomly selected some of those images for a second showing, to see if those were more likely to have been identified in the first round.

“The craziness of the hypothesis was the point,” Lehrer says. “But he wasn’t testing extrasensory powers; he was testing the decline effect.” He continues:

‘At first, the data looked amazing, just as we’d expected,’ Schooler says. ‘I couldn’t believe the amount of precognition we were finding. But then, as we kept on running subjects, the effect size’ – a standard statistical measure – ‘kept on getting smaller and smaller.’ The scientists eventually tested more than two thousand undergraduates …’We found this strong paranormal effect, but it disappeared on us.’

OK, are we talking science, or X-Files? I find this particular episode – both in its original, depression-era version and in Schooler’s 1990s remake – fascinating, even thought-provoking. But these don’t change my confidence in the scientific method one iota.

He moves on to consider a zoologist in Uppsala, Sweden, who published on symmetry and barn swallows’ mating preferences, aesthetics and genetics whose Nature-published theories on “fluctuating asymmetry” haven’t stood the test of time. After an initial blitz of confirmatory reports and curious, related findings, the observed results diminished. Another scientist, said to have been very enthusiastic about the subject and who tried to reproduce them with studies of symmetry in male horned beetles, couldn’t find an effect. The researcher laments:

‘But the worst part was that when I submitted these null results I had difficulty getting them published. The journals only wanted confirming data. It was too exciting an idea to disprove…’

Next, Lehrer advances toward a more general discussion on bias in scientific publishing. This can only partly explain the decline effect, he says. Intellectual fads and journal editors’ preferences for new and positive results lead to imbalance in reporting. Publication bias distorts the reporting of positive clinical trials over negative or inconclusive results. No argument here –

Still, the problem goes deeper. Lehrer interviews Richard Palmer, a biologist in Alberta who’s used a statistical method called a funnel plot to evaluate trends in published research findings. What happens, Palmer says, is that researchers are disposed (or vulnerable?, ES) to selective reporting based on their unconscious perceptions of truth and uneven enthusiasm for particular concepts. He gives an example:

…While acupuncture is widely accepted as a medical treatment in various Asian countries, its use is much more contested in the west. These cultural differences have profoundly influenced the results of clinical trials. Between 1966 and 1995, there were forty-seven studies of acupuncture in China, Taiwan, and Japan, and ever single trial concluded that acupuncture was an effective treatment. During the same period, there were ninety-four clinical trials of acupuncture in the United States, Sweden, and the U.K., and only fifty-six percent of these studies found any therapeutic benefits.

These discrepant reports support that scientists see data in ways that confirm their preconceived ideas. “Our beliefs are a form of blindness,” Lehrer writes. In Wired he quotes Paul Simon: “A man sees what he wants to see and disregards the rest.” The point is clear.

Nearing the end, Lehrer draws on and extends upon David Freedman’s November Atlantic feature, Lies, Damned Lies, and Medical Science, on the critical, outstanding oeuvre of John Ioannidis, a Stanford epidemiologist who elucidates falsehoods in published research.

Re-reading these two articles together, as I did this morning, can be disheartening. “Trust no one,” I recalled. Seems like many – and possibly most – published research papers are untrue or at least exaggerated and/or misleading. But on further and closer review, maybe the evidence for pervasive untruths is not so solid.

In sum, the Truth Wears Off, in last week’s Annals of Science, offers valuable ideas – the decline effect (new), the statistician’s funnel plot (not new, but needing attention) and publication bias (tiresome, but definitely relevant). The ESP story is an obvious weak link in the author’s argument, as is the article’s emphasis and reliance, to some degree, on psychological models and findings in relatively soft fields of research. Physics, genetics, molecular biology and ultimately most aspects of cancer medicine, I know and hope – can be measured, tested and reported objectively.

My approach to new information is always to keep in mind who are my sources, whether those are authors of an article I’m reading or a doctor who’s making a recommendation about a procedure for someone in my family, and the limitations of my own experiences. I’m skeptical about new drugs and medical tools, but determinately open-minded.

The problem is this: if we close our minds to all new findings, we’ll never learn anything. Nor will we ever get better. Sometimes scientific reports are accurate, life-saving or even paradigm-shifting; if only we could know which those are –

“When the experiments are done, we still have to choose what to believe,” Lehrer concludes.

He’s right; I agree. Our choices, though, should be informed – through literacy, multiple sources of information, and common sense.


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Watching the Happy Hospitalist’s Xtranormal Videos

Some weeks ago I discovered Happy’s hilarious Xtranormal videos on his anonymous blog. Yesterday I laughed watching the Hospitalist vs the ER:

I can’t tell you much about who the Happy Hospitalist is. His is one of the few anonymous blogs I read. Based on the apparent relevance of cars and parking lots in his everyday life, I doubt he’s anywhere close to Manhattan. On politics – a tangent on the said Hospitalist’s site, most often I’m not on the same page. But on the ins and outs, and ups and downs of hospital care and personalities at work, most often he’s spot on – with instructive, occasionally deep, specifics and humor.

At the footer of Happy’s blog, beneath an image with a picture of two perky dogs in a vehicle, a caption reads: “IF YOU ARE READING THIS, YOU NEED TO FIND SOMETHING ELSE TO DO. GO SPEND TIME WITH YOUR FAMILY.”


Xtranormal’s mission is to bring movie-making to the people, according to its website. (I aspire to try the “text to movie” function after I’ve published my first book, in 201?)

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Note to Self and to Physicians, Division Chiefs, Hospital Administrators and Everyone Else With Responsibilities for Other Humans

(and to Other Physicians, Division Chiefs, Hospital Administrators and Everyone Else With Responsibilities for Other Humans):


Yesterday I started but didn’t complete a post on the interesting concept of the Decline Effect. I got caught up with several extra-ML responsibilities that kept me busy until very late last night, which became morning before I knew it. I sensed my tiredness, and delayed that short essay for fear of writing something erroneous on the Internet.

Today I had to get up extra early for a meeting. My mind wandered, and I contemplated my fatigue.

I realized that I used to feel like this often when I was practicing, and especially when I returned to work after my cancer treatments and major back surgery. On nights and weekends, working as an attending hematologist and oncologist and caring for patients who were critically sick, I would get called constantly and, not infrequently, have to go to the hospital at odd hours. The work was exhausting.

Residents’ and fellows’ hours are regulated now, and they were then in New York State. But for senior physicians, including many older and frailer than I am, there’s no limit on the consecutive hours they might be responsible for patients’ lives.

Reminder: Without sufficient rest, you can’t think as clearly as you might or should.

No one should be staying up late or all night and then be performing surgery, calibrating humans’ heart rhythms or even just ordering labs. It’s not worth it.

All the physicians I know are real people. Many excellent doctors are too old to pull all-nighters. Our health care system needs evolve so they can take better care of themselves and keep caring for others.

That’s it for today.


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The Word of the Week is Cyberanarchist

The word of the week appears on the front page of today’s New York Times in an article on a crowd-sourced response to WikiLeaks: “the Internet assaults underlined the growing reach of self-described “cyberanarchists,” antigovernment and anticorporate activists who have made an icon of Mr. Assange, a 39-year-old Australian.”

You won’t find a cyberanarchist reference in my old copy of the Oxford English Dictionary. A search led me to a 1998 Chicago Law Review article considering the “fundamental question of whether the state can regulate cyberspace at all.” Another hit led me to a site called, which I don’t recommend to my readers unless you’re really, really into repetitive heavy metal with uninterpretable words set to a screen-filling red anarchism “A” symbol comprised of tiny flickering 0’s and 1’s.

The origins of the compound word are a bit interesting. According to the on-line edition of the Merriam-Webster Dictionary:

Cyber is a new prefix: “of, relating to, or involving computers or computer networks (as the Internet),” with first known use around 1991.

Anarchist is one who rebels against government or espouses anarchy, with origins listed: “Medieval Latin anarchia, from Greek, from anarchos having no ruler, from an- + archos ruler …First Known Use: 1539″

I searched for a deeper meaning of cyber and found little. The only credible thing I came upon in English is on


…the study of human control functions and of mechanical and electronic systems designed to replace them, involving the application of statistical mechanics to communication engineering.

I’ll let my readers and other word enthusiasts take it from here –

There is, of course, an @CyberAnarchist on Twitter, but as of this morning he or she has only 6 followers, tweets nothing and follows no one. A pre-emptive strategy?

The non-etymological, semi-medical lesson in this: be careful!

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Twitter, The Notificator, and Old Social Media News

A series of clicks this morning brought me to an interesting web finding in a Wiki-like Dead Media Archive that links to NYU’s Steinhart School of Media, Culture, and Communication.

Dead Media Archive, NYU Steinhardt School of Media, Culture and Communication

And there rests the Notificator, said (by me) to be Twitter’s great-great-great grandfather, with details:

On September 9, 1932, the London Times printed an article following up on a “correspondence in The Times proposing that British railway stations might, like those in Japan, provide facilities for messages from one person to another to be displayed.” An electrical engineer had written to the paper, agreeing, and noted a device that he had heard of; an “automatic machine…to be installed at stations and other suitable sites, and on the insertion of two pennies facilities were given for writing a message that remained in view for two hours after writing.”

The archive cites the August 1935 issue of Modern Mechanix & Inventions Magazine: “To aid persons who wish to make or cancel appointments or inform friends of the whereabouts… the new machine is installed in streets, stores, railroad stations or other public places where individuals may leave messages for friends… The machine is similar in appearance to a candy-vending device.”

In case you’re interested, my starter source was today’s post on Get Better Health by Dr. Westby Fisher on the Pros and Cons of Social Media for doctors. There, a link in a list “you may also like these posts” drew my eye: Twitter First Conceived By British Hospital In 1935. That July, 2009 post by Berci of ScienceRoll, included an image of an unidentified old-appearing newspaper with an intriguing photo of a man with a hat pointing to a strange device with the word “Notificator” at its top.

A Google search of the headline, “Robot Messenger Displays Person-to-Person Notes in Public” led me to a 1935 Modern Mechanix issue (with the fabulous logo, “YESTERDAY’s Tomorrow TODAY”), some Russian blogs and, finally, the Dead Media Archive, based in principle if not in fact, somewhere near my home in Manhattan, 3 miles or so north of NYU.

This Web find is a good example of how social media and on-line reading can accelerate learning and finding new (and in this case old) ideas. And what goes around comes around –

The Dead Media Archive brims with interesting stuff, worth a virtual visit!

I may go check it out in person, sometime later, for real, if that’s possible –

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