The King’s Speech is Not Just About Stuttering

Over the weekend I went to see the King’s Speech. So far the film, featuring Colin Firth as a soon-to-be-King-of-England with a speech impediment, and Geoffrey Rush as his ill-credentialed but trusted speech therapist, has earned top critics’ awards and 12 Oscar nominations. This is a movie that’s hard not to like for one reason or another, at least most of the way through. It uplifts; it draws on history; it depends on solid acting.

What I liked best, though, is the work’s rare depiction of a complex relationship between two imperfect, brave and dedicated men. At some level, this is a movie about guys who communicate without fixating on cars, football (either kind) or women’s physical features. Great! and, dear Hollywood moguls, can we have some more like this, please?

The film’s medical aspects are four, at least: the stuttering, the attitude of physicians toward smoking, a closeted sibling who had epilepsy and died at an early age – just mentioned in passing, and, finally, the king’s trusted practitioner’s lack of credentials.

King George VI (Wikimedia Commons)

At the start, Prince Albert (young King George VI) has a severe speech impediment. It’s said that he stutters, and on film Firth does so in an embarrassingly, seemingly extreme and compromising degree. He’s the second of George V‘s sons, and might or might not succeed to the throne depending on events in history, his older brother’s behavior, and his capacity to serve the Empire at the brink of war. Being effective as King of England in 1936, and especially at the start of war in 1939, entails speaking confidently.

Prince Albert’s been through the mill with doctors who’ve tried to help him talk. Some recommend he smoke cigarettes; these, they advise, would help him to relax and, they say, is good for the nerves. One asks him to speak with a mouthful of marbles, on which this doctor watching the film worried he might choke. Eventually Albert’s wife, Elizabeth (Queen Mother to be), finds a speech therapist in London, Lionel Logue, who uses unorthodox approaches with, by rumor, exceptional results. Eventually Prince Albert – or “Bertie” as the therapist insists on calling him – trusts and accepts help from this peculiar Australian who, it turns out, developed his methods of assisting stutterers through his work with shell-shocked soldiers in WWI.

According to MedlinePlus, stuttering affects as many as 1 in 20 children, with typical onset before the age of 5. The problem can persist for weeks or years, of manifold causes. Some families are disproportionately affected, but there’s no known genetic cause. Stuttering can arise upon emotional trauma. It’s more common in boys than in girls.

As for doctors recommending cigarettes, the concept is familiar from some old literature regarding schizophrenia. In a recent post, I included a curious TV ad featuring doctors smoking Camels. I don’t have a good sense of just how comfortable most physicians were with smoking prior to 1950, and would like to know more. Did they have their suspicions?

Finally, on the relationship between the king-to-be and Mr. Logue, it’s fascinating: Prince Albert prefers to call his therapist “doctor,” but Logue is adamant that they refer each to the other on a first-name basis. Well into the film, we learn that Logue hasn’t ever attended speech therapy school, or medical school, or whatever it is that someone who treats another person in London circa 1930 should have completed before providing quasi-medical, essentially psychological care as he did to his royal highness. Nonetheless, the king trusts Logue more than any suitably-credentialed therapist recruited by his staff. This topic – of the therapeutic relationship, trust and expectations – warrants separate attention.

Meanwhile, I hope you have the chance to see this movie, if you haven’t already. The Oscars are scheduled for February 27, just two weeks away.

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Quote of the Day, on Health and Discrimination in Hiring

From an article in today’s New York Times on hiring discrimination against people who smoke:

“There is nothing unique about smoking,” said Lewis Maltby, president of the Workrights Institute, who has lobbied vigorously against the practice. “The number of things that we all do privately that have negative impact on our health is endless. If it’s not smoking, it’s beer. If it’s not beer, it’s cheeseburgers. And what about your sex life?”

I think he’s right, more or less, in a slippery-slope sort of way, seriously –

Lots to think about this weekend!

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More News On Lymph Nodes and Breast Cancer Surgery

Last week the New England Journal of Medicine (NEJM) printed a major research article on lymph node dissection in breast cancer surgery. When I first saw the Times’ recent headline, I thought it would cover this paper: Effect of Occult Metastases on Survival in Node-Negative Breast Cancer.*

It turns out there were separate articles on axillary node dissection after sentinel node biopsy in breast cancer – one in JAMA and one in the NEJM – published a week apart. For some reason, the NEJM paper got little attention in the media.

In the work reported in the NEJM, investigators based at the Univ. of Vermont evaluated if the presence of occult metastases – cancer cells found upon further examination of dissected lymph node specimens after the sentinel nodes were deemed negative – affects survival in women with early-stage breast cancer. What they found was that yes, it does: there’s a small but significant reduction in overall survival and disease-free survival at 5 years in women who have “negative” sentinel nodes but turn out, upon more detailed path inspection, to have some malignant BC cells in the armpit.

Kinda scary for someone like me, who had a negative sentinel node. The Vermont investigators determined that 16% of us have occult mets. Of those, 11.1% would be isolated tumor-cell clusters (less than 0.2 millimeters in greatest dimension), 4.4% micrometastases (between 0.2 and 2 millimeters) and 0.4% macrometastases (larger than 2 millimeters), all as classified by the American Joint Committee on Cancer.

On the other hand, the results were generally favorable all-around:

“The 5-year Kaplan-Meier survival estimates for patients in whom occult metastases were detected were 94.6% for overall survival, 86.4% for disease-free survival, and 89.7% for distant-disease–free interval; the survival estimates for patients in whom occult metastases were not detected were 95.8%, 89.2%, and 92.5%, respectively.”

Some details on the well-done study I feel compelled to insert here, a vestige of my thrice-weekly-journal-clubs-in-academic-medicine days:

The Vermont study is strong from a statistical standpoint: The researchers examined stored pathology samples from 5611 women with operable, clinically node-negative BC who were already registered in a large multicenter clinical trial (NSABP B-32). The study participants were randomized to receive either sentinel node dissection or sentinel node dissection followed by full axillary lymph node dissection.

It was a prospective analysis, and the median time on study was just under 8 years. Of the 5611 women enrolled, 3887 (~70%) had negative sentinel nodes and sufficient pathology material available for evaluation. Oncologists treating the patients were “blinded” to the data regarding occult mets, so that they wouldn’t be influenced in their treatment decisions. Among the women with negative sentinel nodes, 1927 underwent sentinel node dissection followed by axillary node removal and 1960 got sentinel node dissection only (based on the earlier randomization).

One result not emphasized in the paper was that removing additional nodes, after the sentinel lymph node exam, didn’t affect the clinical outcome in women with or without occult mets. This finding ties in with this week’s JAMA report, covered separately.

It’s a long article, probably of more interest to pathologists and BC oncologists than to the average reader here. There’s a lot interesting detail, including subtle results of planned subgroup analyses, on the prognostic significance of different kinds (sizes) of occult mets.

I know from my experiences – mainly lately as a friend of people with BC who, in the past few years since sentinel node studies have become the norm – that these issues regarding the significance of occult mets bear on everyday decisions patients make together with their oncologists: how much chemo to take?; should I get radiation to the axilla if there’s a tiny cluster of cells found?; should we add Taxol to the regimen? etc.

These are very real, every-day questions in oncology, and the answers aren’t obvious. But I do think the carefully-established findings reported in this paper will shed light, in an incremental sort of way, on how to best treat BC in women who have negative sentinel nodes at surgery.

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Breast Cancer Study Shows No Benefit In Extensive Lymph Node Removal

Today’s Times leads with a story on surgical removal of lymph nodes in women with breast cancer. The dramatic digital headline, Lymph Node Study Shakes Pillar of Breast Cancer Care, made me tremble at first glance. The article by Denise Grady covers a new report* in the Journal of the American Medical Association (JAMA).

The key finding is that for women with apparently limited disease before surgery who undergo subsequent radiation and chemotherapy, taking out all the cancerous nodes from the axilla (armpit) has no advantage.

I read the original publication and took some notes:

The randomized study, carried out by the American College of Surgeons, involved 891 women with early-stage breast cancer without palpable lymph nodes in the armpit. All underwent lumpectomy and sentinel lymph node examination that was positive – meaning that pathologists observed malignant cells in a sentinel lymph node. Half of the women underwent complete axillary lymph node dissection, by removal of 10 or more lymph nodes, and half did not undergo removal of additional nodes. All of the patients received radiation therapy and the overwhelming majority (>96%) got chemotherapy. The proportions of women treated with endocrine therapy were similar between the two treatment groups.

What the researchers found was that removing additional glands didn’t improve survival in women who had positive (involved) sentinel nodes upon lumpectomy. Survival was measured at 5 years, and the median follow-up was 6.3 years. There was no difference in overall or disease-free survival. This finding supports that for breast cancer patients who will have radiation and chemotherapy, it’s OK for surgeons to leave malignant lymph nodes in place rather than remove those by more aggressive surgery.

Why this matters:

In the majority of BC patients, the lymph nodes in the armpit are not noticeably enlarged at the time of diagnosis. But one in five will have a malignant node detected at surgery. Up until now the standard of care would include a complete axillary lymph node dissection in those women. This procedure can lead to lymphedema, a condition of chronic arm and hand swelling that can be painful and disabling. Lymphedema affects a small but significant fraction of the growing ranks of women – approaching 3 million in the U.S. – who are alive after breast cancer treatment.

According to the Times article, the new research findings could eliminate the need for axillary lymph node dissection in as many as 40,000 women in the U.S. each year: “The discovery turns standard medical practice on its head.”

I’m not so sure I’d go so far as saying that – mainly because I don’t find the results surprising. But I do think it’s a study that matters: The implications bear on costs of breast cancer care (and, yes, on the “costs” of mammography and finding BC) and should have a positive effect on the quality of life for millions of women living after breast cancer treatment. There’s the potential to reduce surgery, and its complications, for the majority of new breast cancer cases.

Why aren’t the results surprising?

Breast cancer treatment, and our understanding of breast cancer biology, has advanced steadily in the past 25 years.

Now it’s routine to give treatments – like chemotherapy, hormone modulators or antibodies like Herceptin – that target breast cancer cells where-ever they reside in the body. The whole point of adjuvant therapy is to destroy malignant cells remaining after surgery. If there are some residual lymph nodes with malignant cells in the armpit region, those would likely be destroyed by chemotherapy and other treatments, combined with radiation to the affected chest and underarm area.

What are the study’s limitations?

What’s not adequately addressed is the situation for women who undergo mastectomy and don’t get radiation, as is standard after lumpectomy.

Another limitation is the study’s relatively short follow-up, of just over 5 years. This is a valid concern in any study of BC survival, but my own opinion is that the axillary node intervention is unlikely to result in a big difference later on. That’s because in 2011 what matters most for treatment decisions, after diagnosis and initial surgery, is the nature – in terms of genetic and molecular features – of the malignant cells.

It happens the NEJM ran a relevant paper on sentinel node dissection last week; we should explore those findings, tomorrow.

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Pink’s OK With Me

On Sunday, Feb. 20, the Northeastern Pennsylvania Affiliate of Susan G. Komen for the Cure will host its seventh annual Pink Elegance on Parade fashion show at the Radisson at Lackawanna Station hotel, reports the Scranton Times Tribune. The fundraiser will feature breast cancer survivors and others modeling fashions from Coldwater Creek, Lee’s Denim Diner, Luna Bleu and Suburban Casuals.

Portrait Of A Lady In Pink Ribbons, by Raimundo Madrazo (Wikimedia Commons)

Some BC survivors, thrivors, thrivers, in-the-throws-ers and whatever we might call ourselves (I still can’t make up my mind on this) express disdain. Others, lately, convey cynicism, if not frank contempt, for the pink cancer culture in its entirety.

Pink is tacky, pretty and possibly too rosy a color to link with the fate of so many sick and dying women. I half-agree. But then again, I’ve never favored pastels: I’m a brown and gray sort of woman. When I’m feeling cheery, I wear navy or maybe mauve. This is not a policy statement; it happens those hues match my skin tone and nature.

Yes, I and others have written that it can be off-putting, that it clouds and distracts us from the reality of cancer. But it takes a certain confidence to don a magenta outfit and not feel silly or excessively feminine (if there is such a thing), as I would, regardless of one’s BC status or awareness level. So I give women credit for wearing pink. And I’m half-envious, besides.

If you’ve had breast cancer and wear pink – why not? I fear the anti-pink movement is making people feel bad about wearing pink to show support for breast cancer awareness, fundraising and related issues. Which is ridiculous. People with breast cancer and their supporters should wear what they want and do as they please, at least wardrobe-wise.

So all power to you, women in Scranton and BC fundraising friends! Show off those post-treatment non-breasts. Be pretty in pink, and proud!

And I’m sure you won’t mind if I wear gray. In the end, isn’t this about supporting one another, and tolerance?

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Contemplating Diet and Nutrition: A First Look at the USDA’s New Guidelines

On Sunday afternoons I tend to think about food for my family. Sometimes that’s because we’re having a few more than usual at the dinner table. Also, it’s a time when I order the bulk of fish, meat, produce and other ingredients for the week ahead.

Since I had cancer, I’ve paid much more attention to the food I serve in our home than before. While a balanced diet is no fail-safe for avoiding disease, I do think it’s prudent to be aware of the variety and quantity of food we eat. In medical school we learned surprisingly little about nutrition. Most of what I know I’ve learned from reading books – like Michael Pollen’s In Defense of Food – and reading through detailed reports like the USDA’s new Dietary Guidelines for Americans (7th Edition) issued a few days ago.

From the press USDA and HHS joint press release:

Because more than one-third of children and more than two-thirds of adults in the United States are overweight or obese, the 7th edition of Dietary Guidelines for Americans places stronger emphasis on reducing calorie consumption and increasing physical activity.

The Times summed up the new guidelines nicely in its headline: Government’s Dietary Advice: Eat Less.

But it’s not a trivial report. Rather, it’s a hefty-if-printed (I didn’t) 112-page pdf with some fluff (even blank pages for notes) and some excellent, hard-to-find-elsewhere details on nutrients. Some highlights include Figure 5-1, which demonstrates with abundant clarity that we don’t eat sufficient fruits, vegetables, whole grains or most other recommended foods:

I’m still digesting (sorry, I can’t help myself) detailed chapters and tables in the full report. There’s a lot of useful information to take in. For example, Appendix 11, on p. 85, charts the “Estimated EPA and DHA and Mercury Content in 4 Ounces of Selected Seafood Varieties” – handy if you serve fish for dinner at least twice per week, and like me, figure it’s best to hedge on potential toxic effects by serving a variety of fish.

More from the press release, on tips that will be provided to help consumers translate the Dietary Guidelines into their everyday lives:

• Enjoy your food, but eat less.

• Avoid oversized portions.

• Make half your plate fruits and vegetables.

• Switch to fat-free or low-fat (1%) milk.

• Compare sodium in foods like soup, bread, and frozen meals – and choose the foods with lower numbers.

• Drink water instead of sugary drinks.

All of these seem wise, but obvious. Still, it’s clear that most of us aren’t following the guidelines, or even common sense.

Setting guidelines should help, so teachers in schools and cafeteria-caterers can know what to tell and feed kids, so they develop good eating habits. But really I think that most of the information, if you can call it that – what constitute our dietary habits begun in childhood – has to be cultivated in our homes, the popular culture and community at large. So my plan is to delve further into the USDA report, and elsewhere, and once each week (maybe) post a nutritional ML. I hope it won’t be too simple or boring.

Like a diet, we’ll see how this goes –

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Doctors Enjoy Smoking Camels, in an Old Cigarette Ad

A new Twitter follow led me to LongartsZwolle, a blog by a pulmonologist in the Netherlands. A February 1 post needs no translation:

More Doctors Smoke Camels Than Any Other Cigarette

The clip is said, on YouTube, to be a 1949 commercial for Camel cigarettes. I tried to find more on this, first by clicking on the Camel website, sponsored by the R.J. Reynolds Tobacco Company, but the virtual age filter checkpoints asked me for too much information, so I gave up.

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Note: Using Google translator, I initially found that longarts means “lung” in Dutch. Zwolle is a city north and east of Amsterdam. But @longartszwolle clarified via Twitter: longarts means pulmonologist. – updated by ES, 2/4/11, 9AM.

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A New Twist on Peanut Allergies and Other Allergic Reactions

The current New Yorker unfolds an engaging story on childhood food allergies. As related by Dr. Jerome Groopman, there’s a shift in how some doctors think about how these conditions  are best managed and, even better – might be prevented. The article feeds into the recent discussion that medical science, and even dogma, too-often turns out to be incorrect.

Groopman interviews Dr. Hugh Sampson, director of the Jae Food Allergy Institute at Mount Sinai Medical Center in New York:

…”This increase in the incidence of food allergy is real,” Sampson said when we spoke recently. He cannot say what is causing the increase, but he now thinks the conventional approach to preventing food allergies is misconceived. For most of his career, he believed, like most allergists, that children are far less likely to become allergic to problematic foods if they are not exposed to them as infants. But now Sampson and other specialists believe that early exposure may actually help prevent food allergies.”

I recommend the full read if you can get it: Groopman probes potential causes of discordant food allergy rates in children of different geographic regions. I learned a number of details on how some doctors in the U.S. use protein-breakdown methods desensitize children to food allergies, how in Israel newly-speaking infants are said to ask eagerly for Bamba, a manufactured, peanut-containing snack (which, for the record, I don’t particularly endorse), and how in some cultures parents chew their young children’s food in a manner that might that might facilitate breakdown of complex proteins by enzymes in saliva.

All interesting –

Of course it’s hard to know exactly what’s true in this, and the causes of allergies are likely to vary among children. There’s a randomized LEAP study (Learning Early About Peanut Allergy) in the U.K. that may provide some hard evidence on this one way, or another.

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Discovering Google’s Art Project

Today’s Wednesday web sighting ranks high in awesomeness. I discovered Google’s Art Project through molecular biologist Jessica Palmer’s always-gorgeous Biophemera blog.

The find is Google Art:

The Battle of the Nile, by Philip James De Loutherbourg, Tate Collection

I couldn’t make up my mind which image to capture for this post.

So take a break and explore some of the world’s finest art collections, right at your computer. Call it a mental health exercise if you like, or just go ahead and take a look. It’s fabulous!

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Considering the Significance of a Doctor’s White Coat

A while back, a first-year med student asked me if I think physicians should wear white coats. There’s a debate about it, she mentioned. Indeed, in the spring of 2009 the AMA considered an unenforceable mandate that physicians in the U.S. not wear white coats. The news was getting around that doctors spread infection from one patient to the next by our garments.

My thoughts on this have always been clear. “Yes,” I answered. “But they’ve got to be clean white coats.”

This week I came upon two stories that led me to pick up the thread on the white coat debate. First, a recent post from the Singing Pen of Doctor Jen, by Jennifer Middleton MD, MPH, who writes from western PA:

We physicians might make assumptions about what patients want us to look like, but what does the evidence say?

A cross-sectional survey in Tennessee a few years ago found that patients prefer family physicians who wear white coats (1).  Another study in a South Carolina internal medicine office found that patients “overwhelmingly” preferred physicians in white coats (2).  A Northeast Ohio OB residency found similarly; patients preferred a white coat and professional dress to scrubs (3). A quick PubMed search pulls up the same theme over and over: the patients studied have more trust in, and comfort with, physicians who wear white coats…(hyperlinks inserted by ES)

Today in the New York Times, a piece by Sandeep Jahuar, MD alludes to the issue by its title: Out of Camelot, Knights in White Coats Lose Way. He considers disillusionment of many doctors with medicine as a profession. He writes:

Physicians used to be the pillars of any community. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler you could aspire to become. Doctors possessed special knowledge. They were caring and smart, the best kind of people you could know.

Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future.

As a doctor, I think physicians should wear white coats for several reasons. First, the white coat reminds the wearer that medicine is a special kind of profession, that doctors have extraordinary obligations to patients. Second, the white coat recalls medicine’s basis in science, from which we wouldn’t want to stray too far. Third, it’s to protect ourselves: going home to dinner with your family, loaded with hospital germs, is just not smart.

As a patient, I like it when my doctors where a white coat. It’s reassuring in a primitive kind of way; it makes me feel like the physician is a real doctor who is capable of taking care of me. But the coat should be clean – every day a fresh one, with extra changes if needed.

Of course there are some circumstances when the white coat is appropriately relegated elsewhere: in places like the OR, in most psychiatrists’ offices and in pediatrics – so as not to scare the children, I once learned although I’m not convinced it would.

It takes a certain effort for a doctor to put on a white coat. When I used to get called back in late at night, or after weekend rounds, I’d occasionally just go straight to the patient’s ward or E.R., without stopping by the room where my coat was kept. That was easier, sure, but when I skipped the white coat I felt as if I weren’t fulfilling my part of the deal: to look and act like a doctor should.

Patients need that, usually. And maybe that’s a hang-up, a superficial wanting, a simple reassurance of authority. But maybe it’s also a sign that you’re serious in your duties as a physician, that you’re not cutting corners, that you will do everything you can to fulfill your obligation to the persons under your care, that you know who you are as the doctor.

Maybe, when younger doctors elect not to wear the white coats, for whatever legitimate reasons, or out of laziness in finding a clean one, it’s really that they don’t want the responsibility the coat conveys.

It could also be that they’re just hot, or uncomfortable.

I’ll leave this open, at that.

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