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Don’t Judge Her! An Essay on Angelina Jolie, BRCA, Cancer Risk and Informed Decision-Making

Angelina Jolie at Cannes in 2011 (Wikimedia Commons, attribution: Georges Biard)

Angelina Jolie at Cannes in 2011 (Wikimedia Commons, attribution: Georges Biard)

Before this morning, I never wondered what it’s like to walk in Angelina Jolie’s shoes. Like many, I woke up to the news – presented in the form of an op-ed in the NYTimes – that one of the world’s most beautiful and famous women recently had bilateral mastectomies to reduce her risk of developing breast cancer.

It turns out the 37 year old actress carries a BRCA1 mutation, a genetic variant that dramatically ups her risk of developing breast and ovarian cancers. Her mother, Marcheline Bertrand, died of cancer at the age of 56 years. Jolie would have been 31 years old when her mother died.

As Jolie tells it, doctors estimated her risk of developing breast cancer to be 87 percent. As she points out, the risk is different in each woman’s case. As an oncologist-journalist-patient reading her narrative, I can’t help but know that each doctor might offer a different approximation of her chances. It’s likely, from all that Jolie has generously shared of her experience and circumstances, that her odds were high.

“Cancer is still a word that strikes fear into people’s hearts, producing a deep sense of powerlessness,” Jolie wrote in today’s paper. To take control of her fate, or at least to mitigate her risk as best she could upon consultation with her doctors, she had genetic testing for BRCA and, more recently, decided to undergo mastectomy.

The decision was hers to make, and it’s a tough one. I don’t know what I’d have done if I were 37 years old, if my mother died of cancer and I had a BRCA mutation. There’s no “correct” answer in my book, although some might be sounder than others –

I know physicians who’ve chosen, as did the celebrity, to have mastectomies upon finding out they carry BRCA mutations. And I’ve known “ordinary” women – moms, homemakers, librarians (that’s figurative, I’m just pulling a stereotype) who’ve elected to keep their breasts and take their chances with close monitoring.  I’ve known some women who have, perhaps rashly, chosen to ignore their risk and do nothing at all. At that opposite extreme, a woman might be so afraid, terrified, of finding cancer that she won’t even go to a doctor for a check-up, no less be tested, examined or screened.

What’s great about this piece, and what’s wrong about it, is that it comes from an individual woman. Whether she’s made the right or wrong decision, neither I nor anyone can say for sure. Jolie’s essay reflects the dilemma of any person making a medical choice based on their circumstances, values, test results and what information they’ve been given or otherwise found and interpreted.

How to conclude? Mainly and first, that I wish Ms. Jolie the best and a speedy recovery after surgery. And to thank you, Angelina, for raising this issue in such a candid fashion.

As for the future, Jolie’s decision demonstrates that we need better (and not just more) research, to understand what causes cancer in people who have BRCA mutations and otherwise. My hope is that future women – children now –needn’t resort to, nor even contemplate, such drastic procedures to avoid a potentially lethal condition as is breast cancer today.

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Reading Toms River

When I was a medical resident working at Memorial Sloan Kettering in the late 1980s, some of us joked about the apparently high cancer rate New Jersey. It seemed, though none of us could prove it, that too many of our patients came from the state across the Hudson. Statistics can be tricky, I knew. Sometimes we notice clusters of disease that are just random blips, constellations or flukes.

river landscape, by Frits Thaulow

river landscape, by Frits Thaulow

So when Dan Fagin’s book, Toms River, came out two months ago, I was drawn. The narrative opens with a gripping portrait of a young man whose frame was irrevocably altered by a childhood cancer. It moves on to the history of the small town in central NJ where Ciba, an international chemical company now subsumed by BASF, set up shop in the early 1950s.

The residents hadn’t a clue what was happening to their water. Fagin, an environmental journalist, wades through a half century of dumping, denial, Greenpeace efforts to expose the situation, local citizens’ mixed responses, real estate, some basic and theoretical chemistry, cancer registries and more.

I value this book highly. Toms River could be a lot of places – pretty much anywhere pollution goes unchecked. As the author points out near the end, the problem’s manifest in China now, and elsewhere. It’s a lesson in business ethics, among other things.

The tale intersperses epidemiology and statistics with local politics and individuals’ lives. It reveals just how hard it is to prove cause and effect when it comes to cancer – which, as I’ve said before, is no reason to let industry go unregulated. Because we’ll rarely if ever get definitive, 100%-style evidence that a particular compound causes cancer in humans. Rather, the story points to the need for lowering the threshold for chemicals on the list, and for regulating toxins in manufacturing.

A subtler point, deeper in some ways, is that there are people who don’t want to think about their neighborhood’s water supply or the food they like to eat…”Out of sight and out of mind,” Fagin says in the thick of it. He’s spot-on, there: when a toxic exposure is disconnected from its outcome by decades – and diluted, we tend not to notice or worry.

#humannature

 

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Dr. Edward Shortliffe, on the History and Future of Biomedical Informatics

Last week I had the opportunity to hear and meet Dr. Edward Shortliffe at the New York Academy of Medicine. He’s a maven in the field of biomedical informatics (that would be the “other” BMI), and a pioneer at that. He mentioned that he began working on an electronic health record (EHR) when he was an undergraduate at Harvard in 1968.

Shortliffe emphasized the multidisciplinary nature of the field – that clinicians and computer science-oriented types need be involved for health information technology (HIT) to be effective. “Human health is at the core of it,” he said. The goal of biomedical informatics isn’t for computers to replace humans, he said, but for doctors to learn how to use it – as a tool – so that we (human doctors) can practice better medicine.

He reviewed the 50-year history of the field. The super-simple summary goes something like this: in the 1960s hospitals developed early information systems; in the 1970s, early decision support and electronic health records (EHRs) emerged at hospitals and large institutions; in the 1980s clinical research trials led to databases involving patients across medical centers; in the 1990s, progress in science (especially genetics) led to modern biomedical informatics. Now, the vast work includes clinical, imaging, biology (molecular, genomic, proteomic data) and public health.

Clinical informatics is the newest field supported by the American Board of Medical Specialties.  The first boards will be offered in October of this year, he mentioned.

If you’re interested in the future of health IT, as I am, you might want to take a glance at a perspective published recently by Dr. Shortcliffe and two coauthors, Putting Health IT on the Path to Success, in JAMA. The authors consider the slow pace of implementing HIT, and suggest that the solution rests with patient-centric Health Record Banks (HRBs):

“…Health record banks are community organizations that put patients in charge of a comprehensive copy of all their personal, private health information, including both medical records and additional data that optionally may be added by the patient. The patient explicitly controls who may access which parts of the information in his or her individual account.

I’d like to see these emerge.

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Finding Kindness and Introspection in ‘Half Empty,’ a Book of Essays by David Rakoff

Regrettably, I found the essayist David Rakoff by his obit. It happened last August. The Canadian-born New Yorker died at age 47 of a malignancy. In a reversal of a life’s expectancy’s, the writer’s death was announced by his mother, according to the New York Times.

I was moved to read one of Rakoff’s books, Half Empty, and in that discovered a man who, I like to think, might have been a friend had I known him. It’s possible our lives did cross, perhaps in a hospital ward when I was a resident or oncology fellow, or in Central Park, or through a mutual friend.

The last essay, “Another Shoe,” is my favorite. Rakoff learns he has a sarcoma, another cancer, near his shoulder – a likely consequence of the radiation he received for Hodgkin’s in 1987. He runs through mental and physical calisthenics to prepare for a possible amputation of his arm. He half-blames himself for choosing the radiation years before: “I am angry that I ever got the radiation for my Hodgkin’s back in 1987, although if it’s anybody’s fault, it is mine,” he wrote. “It had been presented to me as an easier option than chemotherapy.” He reflects on his decision as cowardly and notes, also, that it didn’t work.

He wound up getting chemo anyway, a combination – as any oncologist might tell you, but not in the book –that’s a recipe for a later tumor.  So one take-away from this sort-of funny book, among many, is that how doctors explain treatments and options to patients – the words we use – matter enormously, not just in clinical outcomes, but in how people with cancer feel about the decisions they’ve made, years later.

The other part on words, which I love, is a section on the kinds of things ordinary people – friends, neighbors, relatives, teachers…tell people who have cancer. It appears on pages 216-217 of the paperback edition:

“But here’s the point I want to make about the stuff people say. Unless someone looks you in the eye and hisses, ‘You fucking asshole, I can’t wait until you die of this,’ people are really trying their best. Just like being happy and sad, you will find yourself on both sides of the equation over your lifetime, either saying or hearing the wrong thing. Let’s all give each other a pass, shall we?

I look forward to reading more of Rakoff’s essays, and appreciate that he’s given me so much to think about, on living now.

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Image Share Project (Finally) Enables People to Share and Access Radiology Results

Today Laura Landro reports in the WSJ on the Image Share Project. According to her Informed Patient column, people who want to access and share radiology images pertaining to their health, such as MRIs or CT scans, can do so using this program. The platform enables easier transmission of electronic versions of large, detailed images. Pilot medical centers involved include New York’s Mount Sinai Hospital, UCSF and the Mayo Clinic.

a doctor looks at a medical image on a computer (NIH, NIBIB)

a doctor looks at a medical image on a computer (NIH, NIBIB)

The Radiological Society of North America is on board with the program. This makes sense, among other reasons because funding comes from the NIH’s National Institute of Biomedical Imaging and Bioengineering (NIBIB). According to the WSJ: “This is all about giving patients control of their health information and engaging them in their own care,” said David Mendelson, director of radiology-information systems at Mount Sinai and a principal investigator on the project.

I’m fine with this – how could I not be? Great, super, and of course patients should have access to electronic files of their x-ray images! Except why has it taken so long? Hard to fathom that in 2013 we’re exploring “pilot” sites where patients can enroll in a program that allows them to transmit their electronic health images to doctors in other cities.

Sooo 2003, you’d think.

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News on Occupational Exposure to N-PropylBromide, a Neuro-toxin

Yesterday’s NY Times drew my attention with a front-page article on the Occupational Safety and Health Administration (OSHA) and its inability to prevent harm among furniture and cushion factory workers in the U.S.  Even though hundreds of workers in North Carolina handling nerve-damaging glues have developed neurological toxicity, OSHA failed to suppress use of likely chemical culprits.

structure of n-propyl bromide (Wiki-image)

structure of n-propyl bromide (Wiki-image)

Regulating industry is complicated. The Times reporter, Ian Urbina, focuses on a compound, n-propyl bromide, aka nPB or 1-bromopropane, that’s used by “tens of thousands of workers in auto body shops, dry cleaners and high-tech electronics manufacturing plants across the nation.”

Problem is – it’s hard and possibly impossible, based on studies of factory workers, to prove cause and effect. He writes:

Pinpointing the cause of a worker’s ailment is an inexact science because it is so difficult to rule out the role played by personal habits, toxins in the environment or other factors. But for nearly two decades, most chemical safety scientists have concluded that nPB can cause severe nerve damage when inhaled even at low levels…

The lack of absolute proof – that a particular chemical substance has cause disease in an individual –is exacerbated by the fact that many cushion and glue workers’ symptoms, like numbness and tingling, are subjective: At one company, Royale, a ledger of employees’ illness is said to list “Alleged Neurologic Injury.” This phrase reflects the evaluators’ doubt of the handlers’ complaints and, by insinuation, adds insult to injury – some so severe the workers couldn’t button a shirt, feel a cut, bleeding foot, or stand for more than a few minutes.

The government agency that might respond, OSHA, is woefully understaffed. According to the Times:

“OSHA still has just 2,400 responsible for overseeing roughly eight million work sites — roughly one inspector per 60,000 workers, a ratio that has not changed since 1970. The federal budget for protecting workers is less than half of that set aside for protecting fish and wildlife…

Regulation of industry kills jobs, some say – it’s for this reason that some individuals most likely to suffer harm from manufacturing align with corporations. What’s more, if people lack education about chemistry and need employment, they may not choose or know what’s in their long-term best interests. This piece, like the story of Toms River, points to the unfortunate reality that many citizens tolerate and even take pride in a damaging local business, especially if the health problems it causes are insidious, affect some but not all exposed, and the facts aren’t in full view.

 

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Reading and Hearing ‘Bang the Drum Slowly’

image from the 1973 film

Recently I read Bang the Drum Slowly, a 1956 novel by Mark Harris about players on a fictional baseball team. According to the University of Nebraska Press website, this book was once ranked among the top 100 sports books of all time by Sports Illustrated.

This is a rare cancer narrative. I’d give it 4 stars, or maybe even 5 – depending on my mood and your scale. The story’s told from the perspective of the New York Mammoths’ reliable and usually-winning pitcher, Henry Wiggen. With reason, his teammates call him “Author.” Early on, Author learns his team’s less verbal catcher, Bruce Pearson, had traveled, covertly, to Rochester Minnesota for treatment of Hodgkin’s disease.

In the patient’s words, he’s “doomeded.” Author’s immediate response reveals a clear sense of obligation to his teammate: “I will come,” he says, despite that it’s far away and his wife is pregnant. When he gets to the medical center in Minnesota, he finds Bruce looking deceptively well:

“…and in he come, all dressed, all fit as a fiddle, looking as tip-top as I ever seen him, and I said, ‘This is sick? This is why I dropped everything back home and risked my life in a snowstorm and went to the expense of a new wardrobe in Minneapolis?’   (p. 11)

Harris’s insights and skepticism about physicians in white coats and research funding are familiar now. As his protagonist (Author) remarks:

“’…You are the boys that send me 50 letters a day looking for contributions for your rotten hospitals. What do you do with the contributions I send?’

‘We done many great things,’ said the first doctor. ‘We are only human and cannot do everything.’ (p. 13)

This slim work, oddly elegant in its tenderness and guyish language, resonates today. Some of the pertinent issues include Author’s difficulty in keeping the knowledge of his friend’s illness to himself, the others’ varied responses to the catcher’s disease and cope with his looming death, some acquaintances trying to take advantage of the situation while others reach out and help, fear of the disease…It’s loaded!

An unmissable medical message – apart from the work’s cultural aspects – is that the young player with Hodgkin’s lymphoma had what was accepted as an incurable illness back then. Today, approximately 90 percent of young people with that cancer type survive for decades after the illness and may have a full life after treatment. With so much talk about the costs of care, and research, it’s easy to forget that this was a usually-lethal disease, even at the best of medical centers six decades ago.

I plan to see the two cinematic versions of this story. The first appeared on TV in a 1956 episode of the United States Steel Hour, with Paul Newman as Author and Albert Salmi playing the infirm catcher, among others. More of you may be familiar with the 1973 movie, called Bang the Drum Slowly, starring Michael Moriarty and Robert DeNiro.

Toward the end of the book, a character nick-named Piney sings an old tune about a dying cowboy with this verse: “O bang the drum slowly and play the fife lowly, Play the dead march as they carry me on, Put bunches of roses all over my coffin, “Roses to deaden the clods as they fall.” Some of the players mind the music more than others. The author admits feeling sad.

Though I didn’t find much on the original music behind those verses, which probably exists and has a long history, I did find a clip of Emmylou Harris singing a newer song of the same name.

Emmylou Harris sings another version of "Bang the Drum Slowly" (YouTube)

Emmylou Harris sings another version of “Bang the Drum Slowly” (YouTube)

All these “lessons” – stories of patients, from patients, about patients, form a trail.

ES

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Can Anyone Be a Patient Advocate?

The first time I met an official patient advocate, it was the spring of 1991. I was a first-year fellow, learning by treating patients with blood disorders and all kinds of cancers.

A young gay man with low platelets came to see me in consultation. It was his first visit to the clinic. As I walked by the desk on the way to greet him, the receptionist mentioned that the patient was accompanied by an advocate. “He’s from an organization,” she whispered. “Just thought you’d want to know.”

“OK,” I agreed, not sure what to expect.

My patient was a frail, tired-appearing and polite young man in his 20s. He lived in the West Village and was no longer employed, suffering from AIDS. The man who accompanied him was also thin, perhaps 30 years old – like me, then – and what you might call assertive. The advocate explained that he’d stay with the patient during the evaluation and discussion of recommendations. He added that he’d seen a file on me at ACT UP, and that I was “all right.”

We walked into one of the small consultation rooms. I took detailed notes on the patient’s medical history – too long for his age, approximately 23 years. His body was frail and bruised. A bouquet of tiny red spots lined his palate. Similar marks, a bit darker, coated his legs over and above both ankles. We called those – a manifestation of low platelets – petechiae. I reviewed the patient’s prior blood tests, and drew a sample that I might examine his cells under the microscope.  Later on, the patient, advocate and I spoke about his likely diagnosis and treatment options.

This encounter – my first with an advocate – happened approximately 22 years ago. I don’t know the long-term outcome of the patient’s story, but it’s likely he died of AIDS within a year or two of that encounter. He’d already had several serious infections, and his T cells were quite low as I recall. The advocate may have died, too, but I was not privy to his medical history. All I learned about the advocate – over the course of a few visits, and never by my asking him questions – was that he was involved with ACT-UP, that he was extremely familiar with AIDS manifestations, and that he cared that my patient have access to treatment by a considerate doctor.

So who’s a patient advocate, today?

I’ve been wondering about this, in part because I’d like to serve as a patient advocate on a committee and help decide on priorities, meeting agendas and funding for, say, breast cancer research. Some agencies consider that someone like me – a physician who’s had significant illness – can’t serve as a patient advocate at a table with limited chairs, because I have a medical degree. The problem is, I’m on “the other side,” or something along those lines.

"The Sick Woman," aka "The Doctor and His Patient," by Jan Steen, 17th Century, Rijksmuseum Amsterdam (WikiCommons)

“The Doctor and His Patient,” by Jan Steen

It happens that some physicians, including your author at Medical Lessons, are among the fiercest proponents of patients’ rights I know. I support patients’ unrestricted access to information about medicine and new research, to reasonable treatments matching their preferences and values, and to respect from health care providers. At the same time, I’ve seen doctors who, it seems, promote or outright advertise themselves as “patient advocates” on blogs, websites, in books and elsewhere. Suspicious, yes, but not necessarily untrue –

So here’s the question for the crowd: Can a good doctor, or a nurse, or a physical therapist, or any other person employed by the health care system, serve as a patient advocate?

I’m sure I served an advocate for my patients, years ago, while I was practicing, just as I might now, for people with various illnesses. Tell me I’m wrong.

Comments please! How, exactly, might we define a patient advocate? And, while we’re at it – who’s a patient navigator, and what’s the difference?

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What Do We Need Doctors For?

One of the first questions I asked on this blog was, Are Doctors Necessary? In  2010, I wondered if the Internet and other open resources could replace physicians’ advice. Say you’re feeling OK and not obviously sick, you might prefer to just read and draw upon the wisdom of the crowds, Google and books. If you have a pesky symptom, you might just look it up, or pretend it’s not there, and see if it goes away, without seeking a doctor’s input.

Marcus Welby, M.D. (1969–1976), IMDb image

Marcus Welby, M.D. (1969–1976), IMDb

But if you’re sick – if you’re a patient, and not a consumer, in this blog’s lingo – well, then, of course you need a doctor if you want to get well. Physicians are necessary, still, especially if you’ve got a serious illness, like colon cancer, malaria, catatonic depression, rheumatoid arthritis or Type I diabetes, to name a few doctor’s attention-worthy conditions. Even for someone like me, who’s gone through med school, residency, fellowship and spent years giving medical care to other people, having a thoughtful physician – someone whose experience and intelligence I trust – is indispensible.

My doctors help me sort through the literature, if I choose to read it (I don’t always) and figure out what makes sense for me to live without pain and as fully as possible. I value their work immeasurably. But, as much as I have been helped by nurses, physical therapists, pharmacists and peer patients, the doctor’s opinion matters most. Admittedly, I’m lucky in this. Over the years, I’ve accrued a team of excellent physicians whom I trust. That’s not a common scenario now, which is part of why this question matters so much.

The updated part of the question, now, is whether nurse practitioners (NPs), straight RNs, physician assistants (PAs), pharmacists, social workers and others including, yes, peer patients, should take up much – or even most, of doctors’ tasks. As outlined in a recent editorial, these non-physician health care workers can be paid less and may do a better job at certain chores that, historically, have been carried out by MDs. They can order scans and contact patients about the results, fill out forms for home physical therapy, measure your blood pressure and give injections, like flu shots.

At one level, assigning minor and not-so-minor tasks to other kinds of health care providers sounds great. It’s a partial, 2-for-1 solution, because it relieves the physician shortage and, simultaneously, lowers health care costs. It makes perfect sense, to a point, for efficiency.  There are, legitimately, some tasks that nurses are better-trained to do, such as giving medications. Pharmacists are more likely to pick up on dangerous drug combinations than busy pediatricians, because that’s the focus of their work and training. Peer patients are valuable too. Etc.

But if doctors are just thinking about your “case” or doing complex  procedures, and not being the ones to call you back, or putting in intravenous catheters, or even just sitting and taking a thorough history – they’ll know you less well. And if they spend less time with you, a patient with a serious illness, they – according to the laws of human nature, and my observations on rounds on hospital wards over many years – will not care so much about the outcome of your case. When and if a doctor spends time with a patient, that builds trust, concern, and – possibly, better outcomes.

Reality dictates that we have to protect doctors’ time so they can read, sleep, and spend at least a few minutes each day with the people they care about outside of the workplace, and take care of themselves. If we don’t unload some of the tasks to other health care workers, we’d have to assign fewer patients to each physician. That would exacerbate the shortage…

No simple answer –

ES

 

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Contemplating Breast Cancer, Beyond October 2012

It’s foggy today, October 3, ten years since the last mammogram I had and will ever need. I’ve been remiss in updating the blog. The reasons include family concerns and other projects. Meanwhile, I’ve been thinking about the big picture – what’s most important for progress against breast cancer in the decade ahead.

So here’s what I see, now – in terms of three priority areas: improving treatment, prevention, and education to inform treatment decisions.

Pumpkins, organized by subtype (WikiCommons image)

As an oncologist, I perceive huge strides in understanding BC since the time of my diagnosis. But these advances are largely invisible to patients because they’re in the realm of pathology and classification of different subtypes. What was essentially a 3-type malignancy with a handful of treatment options has expanded under the molecular microscope to a spectrum of 4, 10 or – what’s probably most accurate – hundreds or thousands of patient-particular conditions, depending on the level of precision by which you define a disease. I’m optimistic, because it looks as though, in my lifetime, BC treatment will be tailored to each patient. There’ll be less surgery and better drugs.

The hitch, now, is not so much with science as with funding– funding to analyze each patient’s tumor at the genetic and protein levels, funding to pay for treatments selected by patients (which might include less treatment and/or palliative care in advanced cases), and funding to educate doctors about BC subtypes and medical progress, so they might offer “modern” advice to each patient in ordinary clinics, apart from clinical trials and academic centers. Newer is not always better in medical care. Same goes for more treatment (especially when it comes to higher doses). Still, the lag between advances in BC science and application of distinct, targeted and better treatments is frustrating at best.

Some of my colleagues call for patience – emphasizing that studies need be confirmed, drugs tested in mice, etc. Their point is that we can’t jump from pathology research and new BC classifications to new therapy. But one lesson I take from progress against AIDS is that maybe we shouldn’t be so patient. At least not for young people with poor-prognosis BC subtypes or stage. We could do studies and studies of particular BC treatments, and studies of studies (those would be meta-analyses) and debate 8 or 10 years from now whether a particular drug or combination of drugs worked in clinical trials that selected for patients with an antiquated subtype of the disease. Or we could move toward “n=1” trials, with smart, well-trained physicians assessing each patient by a combination of old-fashioned physical exams and the most modern of molecular studies of the tumors, considering the options, and moving forward with individual, mini-experimental treatment plans.

I vote for the latter. If the drug works in a patient with advanced BC and the patient feels better, why not?

For people with early-stage BC, prescribing or taking new and essentially untested drugs makes less sense at first glance. That’s because standard treatments are “successful” – leading to long-term remissions and possible cures in over 80 percent of those affected. But these relatively good results may have, paradoxically, hampered development of better drugs that could obviate the need for breast-deforming surgeries and radiation in many women. The possible application of BC drug cocktails, in lieu of surgery for early-stage patients, is a huge question for the future, and one for which trials would be necessary. Just getting those projects going – applying BC science to treatment of early-stage cases – would be a step in the right direction.

As for BC prevention, of course that would be infinitely better than detecting or treating the disease. Unfortunately, I think we’re farther away from preventing the disease than we are from having effective and less brutal treatments for most patients. The problem with lifestyle modification – like staying active and not obese – is that it’s far from full-proof: You can be seemingly fit as a fiddle and get a lethal case of BC. Still, there are plenty of other health-related reasons for women to exercise and eat sensibly. As for avoiding carcinogens or, first, just knowing what chemicals contribute to BC formation and growth, the science isn’t there yet.  It’ll be a long haul before anyone can prove that a particular chemical causes this disease. That said, I advocate research in the slow-growing field of environmental oncology and wish there’d be more enthusiasm for regulating our exposure to likely-toxic chemicals.

The third priority is for improving education in math and science, starting at the elementary school level. Doctors need to understand statistics, but many don’t. They need to know about genomics and basic science in medicine. Patients need this kind of knowledge if they want to have a clue, if they want to engage meaningfully in decisions about which antibody to take, or pill, or whether they want to participate in a clinical trial of pills instead of surgery for a Stage II tumor with high levels of Her2, for example. That’d be a tough decision for an oncologist. I only wish that we could reach the point where we could have those kinds of truly informed conversations about clinical treatment of breast cancer, which happen every day.

We’ve got a lot of information in hand, but we need to learn how to apply that to more patients, faster and more openly.

All for a while. I’m open to ideas on this. Happy October!

ES

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A Comedian Tells the Story of His Child’s Cancer

Yesterday a video came my way on Facebook. It’s a stand-up piece by Anthony Griffith, who tells what it was like working as a comedian when his 2-year old daughter had recurrent cancer and died.

This 9 minute clip packs sadness and pain:

The Moth Presents Anthony Griffith

“If you don’t know about cancer, when it comes back it comes back hard.” It’s “meaner and stronger,” he explains. To compensate for its added aggressiveness, doctors raise doses of chemo and radiation. That’s not easy for anyone, a child no less.

He reflects on his daughter’s condition back then: “So she’s bald, which she doesn’t mind because every kid in the ward is bald, and she thinks it’s a part of life…”

He recalls his predicament, as a parent: “You’re not prepared for this. There’s no books, there’s no home-ed class to teach you,” he says.  Therapists were off-limits in his community. “So you try to figure it out.”

“What did I do?” he wondered, trying to make sense of his daughter’s illness. His musings cross all kinds of barriers.

Griffith was thrilled to appear several times on Johnny Carson’s Tonight Show. But NBC is “all about nice and everything is going to be OK.” He felt pressured to keep everything “light” when he wanted to speak honestly.

He recounts how he felt. “And I’m hurting, and I want everyone else to hurt because somebody is to blame for this,” he shouts, two decades later. He suppressed his anger, bucked up, and performed.

Rage persists, understandably, still.

The powerful clip is produced by the Moth, an NPO dedicated to storytelling. H/t to Jen Singer.

Thank you to Mr. Griffith, the comedian and actor, for telling it like it is.

 

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Don’t Blur the Message on Cancer Screening

This week the USPSTF renewed its position on ovarian cancer screening. The panel reminded the public that there’s no value in doing blood tests, like measuring the CEA, or having sonograms to evaluate healthy-feeling women for the possibility of ovarian cancer. One problem with the CEA measurement is that it goes up in various conditions; it’s not a specific test. Similarly, abdominal ultrasounds tend to pick up all kinds of blobby images that are rarely ovarian tumors. More often than not, ovarian cancer screening tests lead women to undergo more tests, such as CT scans and even surgery, without any benefit. The CEA tests and ultrasounds rarely “catch” ovarian tumors in an early stage.

This information on the lack of effective ovarian cancer screening methods is hardly news. What I hope is that this week’s headlines and editorials don’t add to the blurriness of the public’s perception of cancer screening – that people might think it’s a bad thing all around. The details matter. For some cancers, screening the general population – if it’s done right – can save lives and dollars. That’s because for most tumor types, treating advanced, metastatic disease is costlier than treatment of early-stage, curable tumors.

A few words on other cancers and screening –

Prostate cancer screening by PSA testing has never been shown to save lives. Because prostate cancer is unusual in young men and occurs commonly in elderly men, and in those cases tends to be slow-growing, screening’s potential – even if it were safe and effective – to save men’s life-years is limited. What’s different, also – and I think this is where some journalists get the story wrong by omission – is that early treatment of prostate cancer is rarely beneficial. By contrast, early treatment of breast cancer is often life-saving.

Lung cancer screening may be helpful in people at high risk, such as smoking, but one could argue that the CT scans used in those studies – which involve more radiation exposure than do mammograms, besides that they’re more costly – need a higher threshold of benefit to justify their use.

Colon cancer screening has been shown to save lives. For this tumor type, I think the issue is whether it’s worth doing colonoscopy in everyone over the age of 50, periodically, or better to test everyone for tiny amounts of blood (or, in the future, cancerous DNA markers) in the stool. Checking for occult blood in stood samples is a simple and perfectly safe method of getting a little bit of information about the probability of someone having a polyp or frank malignancy in the gut. If people who want to be screened for colon cancer would reliably take a sampling, it’s possible they might safely skip colonoscopy if there’s no evidence for bleeding or other signs of disease.

As for cervical cancer screening, that has definitely been an advance. Pap smears and other liquid cytology methods, now, perhaps HPV testing, have successfully countered this disease. Years ago, women would present, typically in their 30s, 40s or 50s, with large cancers pushing into the body of the uterus and lower abdomen. These were rarely curable. Rather than a scrape, or slightly bigger procedure in a gynecologist’s office, the women needed hysterectomies and radiation to the pelvis, which caused problems down the road if they were lucky and survived. In communities where young women get gynecological care now, we rarely see advanced cases of cervical cancer. For this disease, the question now is in fine-tuning the frequency of screening and understanding how HPV tests can inform or supplement the Pap smear.

As for mammography in breast cancer screening, please don’t get me wrong. I am not fixed in my position that it’s worthwhile and should be performed every other year in most women over the age of 40 until they reach the age of 70 or so, depending on their wishes and overall health. Rather, I acknowledge it’s far from a perfect screening tool, and I genuinely hope that in the future we’ll prevent breast cancer entirely or at least find a better, safer way to detect it early on. But until that happens, for the time being, mammography is a well-established, routine procedure that is the best we’ve got to prevent tens of thousands of middle-aged women from dying every year in the U.S. from metastatic BC.

I generally ascribe to the “less is more” school of medicine. But that doesn’t mean we should ignore early-stage breast tumors, especially when they occur in young-ish women. Rather, it means that we should treat what cancers we do find carefully and conservatively, with the least therapy needed to raise a woman’s chances of leading a normal, healthy and full life.

All for now,

ES

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Notes on the Social History of American Medicine, Self Reliance and Health Care, Today

Over my vacation I read a bit on the history of health care in the United States. The Social Transformation of American Medicine, by Paul Starr, was first published in 1982. The author, a professor of sociology and public affairs at Princeton, gives a fascinating, relevant account in two chunks. In the first section, he details the rise of professional authority among physicians in the U.S. In the second part, he focuses on the relationship of doctors to corporations and government.

I couldn’t put this book down. Seriously, it’s a page-turner, at least in the first half, for anyone who cares about medical education, doctors’ work, and how people find and receive health care. In an early chapter, on medicine in colonial and early 19th Century America, Starr recounts the proliferation of medical schools and doctors, or so-called doctors, in the years after 1812. One problem of that era, besides a general lack of scientific knowledge about disease, was that it didn’t take much to get a medical degree. State licensing laws didn’t exist for the most part, and where they did come in place, such as in New York City, they were later rescinded. Then as now, many practicing folks didn’t want regulations.

Doctors were scarce and not always trustworthy. People, especially in rural areas, chose or had to be self-reliant. Many referred to lay sources for information. Starr writes of the “domestic” tradition of medical care:

…Women were expected to deal with illness in the home and to keep a stock of remedies on hand; in the fall, they put away medicinal herbs as they stored preserves. Care of the sick was part of the domestic economy for which the wife assumed responsibility. She would call on networks of kin and community for advice and illness when illness struck…

As he describes it, one book – William Buchan’s Domestic Medicine, was reprinted at least 30 times. It included a section on causes of disease and preventive measures, and a section on symptoms and treatments. By the mid 19th Century a book by John C. Gunn, also called Domestic Medicine, or Poor Man’s Friend…offered health advice in plain language.

Starr considers these and other references in the context of Protestantism, democracy and early American culture:

…while the domestic medical guides were challenging professional authority and asserting that families could care for themselves, they were also helping to lay the cultural foundations of modern medical practice – a predominantly secular view of sickness…the authority of medicine now reached the far larger number who could consult a physician’s book.

Reading this now, I can’t help but think of the Internet and other popular and accessible resources that challenge or compete with doctors’ authority. Other elements of Starr’s history pertain to current debates on medical education, credentialing and distribution of providers.

Just days ago, for example, the New York Times ran an editorial on a trend of getting Health Care Where You Work. The paper reported on Bellin Health, an allegedly non-profit entity, that designs on-site clinics for medium-sized companies. “It has managed to rein in costs while improving the availability and quality of care — in large part by making it easier for patients to see nurses and primary care doctors,” according to the Times opinion. The clinics are “staffed part-time by nurses, nurse practitioners or physician assistants, who handle minor injuries and illnesses, promote healthy living and conduct preventive screenings.”

The editorial touts Dartmouth Atlas data and other high marks for the care Bellin provides at low costs to possibly happy workers and their satisfied employers. Still, it’s not clear to me that an on-site clinic would be a great or even a good place to seek care if you had a subtle blood disorder or something like the newly-reported Heartland virus.

On reading the editorial on delivering health care to the workplace, I was reminded of Starr’s tale of the development of clinics at railroad and mining companies in the first half of the 20th Century. This happened mainly is rural areas where few doctors lived, at industry sites where injuries were frequent. The workers, by Starr’s account, were generally suspicious of the hired physicians and considered them inferior to private doctors whom they might choose if they became ill. They resented paying mandatory fees to support those on-site doctors’ salaries. Doctors’ groups, like the AMA, generally opposed and even ostracized those “company doctors” for selling out, or themselves, at a lower price.

The second half of the Social Transformation, on failed attempts at reform before 1982, is somewhat but not entirely outdated in light of Obamacare and 40 years intervening. But many of the issues, such as consideration of the “market” for doctors and the number of physicians we need, relate to the papers of this week including an Economix column by another Princeton professor, Uwe Reinhardt, who puts forth a view that, well, I don’t share. As I understand his position, Reinhardt suggests that there may be no real shortage of doctors, because physicians can always scrunch their workloads to fit the time allotted. But that’s a separate matter…

In sum, on the Social Transformation, today: Worthwhile! Curious! Pertinent! Starr’s book is chock full of history “lessons” that might inform medical practice in 2012. And I haven’t even mentioned my favorite segments – on prohibiting doctors’ advertisements (think websites, now), the average workload of physicians before 1900 (think 5 or so patients per day), and the impact of urbanization on medical care and doctors’ lives and specialization.

Lots to think about, and read.

All for now,

ES

 

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Breakfast Will Never Be the Same Again

#Ordinary, heart-wrenching: “I remember one time when my mom asked me to get her a bowl of Cheerios, and we ate them together” – http://bit.ly/OsFfHO

I couldn’t fit the hash-tagged words above, with the link, into 140 characters. So here’s a post for the weekend and school year ahead:

Some of the breast cancer bloggers have been posting lately on the ordinary things that contribute to our well-being. The idea is one I’ve considered previously and attribute in part to Mom-blogger and post-lymphoma person Jen Singer, who once wrote about the immeasurable value of doing laundry, or something like that.

The point is – it’s not all about the vacations in Thailand, birthdays and rock concerts. Or opera, if you’re into that. Rather, it’s the everyday stuff that fills our lives.

Before I get too Hallmarky…

This morning Lisa Fields, aka @PracticalWisdom, sent a Tweet that caught my interest. Nominally, it was on the “geography of verbs” as considered in a commencement address. I clicked. The Guilford College speaker, author Patti Digh, recalled a young family that appeared a few years back on the Oprah show.

The mom was dying, with cancer. Digh recounts:

After she died, Oprah welcomed the family back to her show and asked the kids a question: “What is one of your favorite memories of your mom?” I’m sure Oprah imagined they would talk about swimming with dolphins or one of their big adventures with her, but the little girl said very quietly, “I remember one time when my mom asked me to get her a bowl of Cheerios, and we ate them together.”

Bingo. It’s the little stuff, as Digh explains. What the child – or an adult “survivor” in the sense of one who outlives the person and remembers selectively – values may or may not match what matters most to the patient.

This is the opposite, or at least a twist in perspective, relative to what the bloggers are talking about. And it’s the same. A logical puzzle, maybe, for life.

#EveryDayMatters.

Enjoy the weekend, all!

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Why Hurricanes Remind Me of Patient Care

Last week, Tropical Storm Isaac started tracking toward the Gulf of Mexico. As usual, the prediction models offered varying forecasts. Nonetheless, by this weekend a consensus emerged that the tempestuous weather system would, most likely, affect the City of New Orleans.

National Hurricane Center image

The Mayor, Mitch Landrieu, didn’t panic. I watched him on TV on Sunday evening in an interview with CNN’s Wolf Blitzer and Erin Burnett. Isaac wasn’t a hurricane yet, although a Category I or II storm was predicted by then. He didn’t order an evacuation. Rather, he emphasized the unpredictable nature of storms. There’d be business as usual the next day, on Monday morning August 27. Mind the weather reports, and do what you need to do, he suggested to the citizens. He did mention there’d be buses for people who registered.

“Don’t worry,” was the gist of his message to the citizens of New Orleans. The levees should hold. He exuded confidence. Too much, perhaps.

Some people are drawn to leaders – or doctors – who blow off signs of a serious problem. “It’s nothing,” they might say to a woman who fell after skiing and hit her head, or to a man with a history of lymphoma who develops swollen glands and fever. It’s trendy, now, and sensible, to be cost-conscious in medical care. This is a terrific approach except when it misses a treatable and life-threatening condition or one that’s much less expensive to fix earlier than later.

“Every storm is different,” meteorologist Chad Myers informs us.

Like tumors. Sometimes you see one that should have a favorable course, like a node-negative, estrogen-receptor breast tumor in a 65 year old woman, but it spreads to a woman’s bones within a year. Or a lymphoma in a 40 year old man that looks to be aggressive under the light microscope but regresses before the patient has gone for a third opinion. But these are both exceptions. Cancer can be hard to predict; each case is a little different. Still, there are patterns and trends, and insights learned from experience with similar cases and common ways of spreading. Sometimes it’s hard to know when to treat aggressively. Other times, the pathology is clear. Sometimes you’re wrong. Sometimes you’re lucky….

In New Orleans, the Mayor’s inclination was to let nature take its course. He’s confident in the new levees, tested now by Isaac’s slow pace and prolonged rains. I do hope they hold.

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Talking About Physician Burnout, and Changing the System

Dear Readers,
I have a new story at the Atlantic Health. It’s on burnout among physicians. The problem is clear: Too many have a hard time finding satisfaction in the workplace. Many struggle with work-life balance and symptoms of depression.

With many difficult situations, the first step in solving a problem is in acknowledging it exists. After that, you can understand it and, hopefully, fix it. Our health care system now, as it functions in most academic medical centers and dollar-strapped hospitals, doesn’t give doctors much of a break, or slack, or “joy,” as Dr. Vineet Arora suggested in an interview. You can read about it here. The implications for patients are very real.

Glad to see that research is ongoing about physicians’ stress, fatigue and depression. Thank you to Drs. Tait Shanafelt, Mary Brandt, Vineet Arora and others for addressing these under-studied and under-discussed issues in medicine. Through this kind of work, policy makers and hospital administrators might better know how to keep doctors in the workforce, happy and healthy.

ES

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Living Like It’s Shark Week, Take 3

It’s Shark Week, or at least that’s the situation over at Discovery Channel. The annual, virtual immersion into the world of cartilaginous fish has been adopted by your author as some sort of metaphor, but she’s not sure for what.

“Live every week like it’s shark week” is a puzzle. In fact, this statement in a 30 Rock episode lurks at the periphery of Medical Lessons year-round. By now I should confess I’ve never watched an entire Shark Week program. But that doesn’t stop me from wondering about the significance.

Remotely, it’s about mental health. Science, too. I could head into a discourse on cartilage and the alleged beneficial effects for illnesses like cancer, but I don’t believe there’s any evidence to support those claims. Surely, Shark Week has to do with whether you embrace more risk or take a safe route, swim where divers go or watch TV about nature. At another level, it’s about time – a reminder that there are only so many days and nights in each week, in each month, in each year, by which we mark our lives.

So it’s about mortality. Maybe.

An alternative theory is that Shark Week is entirely devoid of deep meaning. It could be nothing more than a tool by which the Discovery Channel turns a profit in August. This year, the event was delayed until August 12. Although I’ve never taken a course in cable network programming, I would hazard a guess that this scheduling change had to do with the end of the Olympics programming that same day.

For 2012, I’ve decided to celebrate Shark Week by not watching TV. Furthermore, I won’t write on anything that has to do with breast cancer or hard science. This morning, I walked to a beach and went for a swim before breakfast. It was fantastic.

Enjoy August! And please rest up, dear readers, because I’m likely to get serious again, soon,

ES

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Another Take on Not Smoking, the Law and Tolerance

The New Yorker published a story this week, on smoking, that caught my attention. It’s by none other than F. Scott Fitzgerald. The author died in 1940 at the age of 44, after a ruinous period of addictions including alcoholism, debts and other problems.

F. Scott Fitzgerald (June, 1937), photo by Carl van Vechten

Thank You for the Light dates to 1936. The main character is a woman: “Mrs. Hanson was a pretty, somewhat faded woman of forty…” She sold girdles and craved cigarettes. Smoking had the power to “rest and relax her psychologically.” He describes her growing frustration at not being able to take a drag in offices where she did business.

The story suggests that although public and workplace smoking wasn’t illegal back then, it was frowned upon in cities like Chicago. The protagonist longs for past years and places where she could chat and share a drink or cigarette with clients after work. Times had changed, she reflects.

In Fitzgerald’s words:

…Not only was she never asked if she would like to smoke but several times her own inquiry as to whether anyone would mind was answered half apologetically with ‘It’s not that I mind, but it has a bad influence on the employees.’

This vignette offers a 1930s perspective on what some call social health – that an individual’s behavior might be influenced by neighbors’ and coworkers’ attitudes. In this story, the woman finds solace in a church. I won’t give away the ending.

The short read lingers. What’s unsettling, still, is whether the socially-driven ban on smoking helped or harmed the woman.

According to the New Yorker’s Page-Turner, the magazine rejected Fitzgerald’s story when he submitted the piece. The writer’s granddaughter recently uncovered it. This time around, it passed muster.

 

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A Closer Look at the Details on Mammography, in Between the Lines

Recently I wrote a review of Between the Lines, a helpful handbook on bio-medical statistics authored by an acquaintance and colleague, Dr. Marya Zilberberg. In that post, I mentioned my concern about some of the assumptions and statements on mammography. One thing I liked the book, abstractly, is the author’s efforts to streamline the discussion so that the reader can follow the concepts. But simplification and rounding numbers, “for ease of presentation” (p. 29) can mess up facts, significantly in ways that some primary care doctors and journalists might not appreciate. And so I offer what I hope is a clarification, or at least an extension of my colleague’s work, for purposes of helping women understand the potential benefits and risks of mammography.

In the section on mammography (pp. 28-31), the author rounds down the incidence of breast cancer in women between the ages of 40 and 50 years, from “1 in 70” (1.43%) to “1 in 100” (1%). As any marketing professional might remind us, this small change represents a 30% drop (0.43/1.43) in the rate of breast cancer in women of that age group. This difference – of 30%, or 43%, depending on how you look at it – will factor into any calculation of the false positive (FP) rate and the positive predictive value (PPV) of the test.

For women ages 40-49 Have breast cancer Don’t have breast cancer
If estimate 1 in 100, 1.0 % 100 9,900
If estimate 1 in 70, 1.43 % 143 9,857

Keep in mind that these same, proportional difference would apply to any BC screening considerations – in terms of the number of women affected, the potential benefits and costs, for the 22,996,493 women between the ages of 40 and 49 counted in the 2010 U.S. Census,

My colleague estimates, fairly for this younger age group of women (who are relatively disposed to fast-growing tumors), that the screening technology (mammography) only picks up 80% of cases; 20% go undetected. In other words – the test is 80% sensitive; the false negative, FN, rate is 20%. In this same section, she considers that the FP rate as 10%. Let’s accept this (unacceptably high) FP rate for now, for the sake of discussion.

As considered in Between the Lines:

If FP rate is 10%, prevalence 1 in 100 Really have BC Don’t have BC Total
Mammography + 80 990 1,070
Mammography – 20 8,910 8,930
Total 100 9,900 10,000

But the above numbers aren’t valid, because the disease affects over 1 in 70 women in this age bracket. Here’s the same table with a prevalence of 1 in 70 women with BC:

If FP rate is 10%, prevalence 1 in 70 Really have BC Don’t have BC Total
Mammography + 114 986 1,100
Mammography – 29 8,871 8,900
Total 143 9,857 10,000

In this closer approximation to reality, the number of true positives is 114, and false positives 986, among 1,100 abnormal screening results. Now, the PPV of an abnormal mammogram is 114/ (114+986) = 10.4%. So the main statistical point – apart from the particulars of this discussion –  is that a seemingly slight rounding down can have a big impact on a test’s calculated and perceived value. By adjusting the BC rate to its prevalence of approximately 1 in 70 women between 40 and 49 years, we’ve raised the PPV from 7.5% to 10.4%.

Here I must admit that I, too, have rounded, although I did so conservatively very slightly. I adopted a 1 in 70 approximation (1.43%) instead of 1 in 69 (1.45%), as indicated on the NCI website. If we repeat the table and figures using a 1 in 69 or 1.45% prevalence rate and 6% FPS, the PPV rises a tad, to 10.5%.

Now, we might insert a different perspective: What if the false positive rate were 6%, as has been observed among sub-specialist radiologists who work mainly in breast cancer screening?

If FP rate is 6%, prevalence 1 in 70 Really have BC Don’t have BC Total
Mammography + 114 591 705
Mammography – 29 9266 9,295
Total 143 9,857 10,000

As you can see, if we use a FP rate of 6% in our calculations, the total number of FPs drops to 591 among 10,000 women screened. In this better-case scenario, the PPV of the test would = 114/ (114+591) =16%. Still, that’s not great – and I’d argue that public health officials, insurers and patients should be pushing for FP rates closer to 2 or 3% – but that’s irrelevant to my colleague’s point and her generally instructive work.

My second concern has to do with language, and making the consequences of false positives seem worse than they really are. On page 29, the author writes: “ So, going back to the 10,000 women being screened, of 9,900 who do NOT have cancer… 10%, or 990 individuals will still be diagnosed as having cancer.” The fact is, the overwhelming majority of women with positive mammograms won’t receive a cancer diagnosis. Rather, they’ll be told they have “an abnormal result, or a finding that suggests the possibility of cancer and needs further evaluation,” or something along those lines. It would be unusual in practice to jump from a positive mammogram straight to a breast cancer diagnosis. There are steps between, and every patient and journalist should be aware of those.


Finally, if I were to write what I really think, apart from and beyond Between the Lines – I’d suggest the FP rate should be no higher than 2 or 3% in 2012. This is entirely feasible using extant technology, if we were to change just two aspects of mammography practice in the U.S. First, require that all mammograms be performed by breast radiologists who get extra training and focus in their daily work almost exclusively on breast imaging. Second, make sonograms – which, together with mammograms, enhance the specificity of BC screening in women with dense breasts– universally available to supplement the radiologists’ evaluations of abnormal mammograms and dense breasts in younger women.

By implementing these two changes, essentially supporting the practice of sub-specialists in breast radiology, we could significantly lower the FP rate in breast cancer screening. The “costs” of those remaining FPs could be minimized by judicious use of sonograms, needle biopsies and other measures to reduce unnecessary surgery and over-treatment. Over the long haul, we need to educate doctors not to over-treat early stage disease, but that goes far beyond this post and any one woman’s analysis of mammography’s effectiveness.

All for now,
ES

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What Does a Bikini Parade Have to Do with Breast Cancer?

A recurring question on this blog is this: Is there a limit, in terms of appropriateness or “correctness,” in fundraising for causes that would help put an end to breast cancer?

My blogging colleague and friend, fellow BC ~survivor/advocate/NBCC summit attendee and former chemo recipient, AnneMarie Ciccarella, @chemobrainfog wrote about an upcoming bikini parade planned by a tanning salon owner in Madison Lake, MN. Proceeds from the march will go toward a nonprofit group called the Breast Cancer Natural Prevention Foundation (preventbc.org). This true story is problematic at many levels, as AnneMarie points out.

But sometimes an extreme case of something – here what’s billed as a BC fundraiser – can be instructive. A few months ago I wrote about Boobstagram – a French website that asks women to submit pictures of their breasts to increase awareness of the value of healthy breasts. The site, vaguely and with few words, tries connecting the barely clad images with “the fight against cancer.” Although I’m still not convinced that the concept utterly lacks merit in principle, and maintain that some of the voices raised here were, perhaps, too quickly dismissive and uptight about the possibility of fundraising or BC activism by this method, I acknowledge that the men running that company seem to be doing nothing useful in terms of reducing breast cancer or its complications.

The Minnesota bikini march will take place on July 28. The line-up starts at noon. The walk will begin at 1PM. According to the announcement on the Electric Beach Mankato website, “only females in bikinis will be counted toward the world record.” The organizer and salon owner, Cynthia Frederick, needs 451 participants to break the Guinness World Records mark for largest bikini parade. That site lists the record as 357 women, based on a 2011 event in Queensland, Australia. But that achievement was recently surpassed in Panama City, FL. What’s different about the prior demonstrations is that there was no pretense of raising money or awareness to help fight, prevent or cure breast cancer.

Minnesota bikini parade participants will pay $20 or $25 for tee shirts. Net proceeds will to go the Breast Cancer Natural Prevention Foundation. The foundation’s site suggests that sunlight prevents BC by increasing vitamin D levels (which is total BS, to be perfectly clear). Taking too much vitamin D can do damage, as can excessive sun exposure.

As I read this, a tanning salon – a business that causes melanoma and other skin cancers – is promoting a walk of bikini-wearing women in midday summer sun to break an amusing world’s record. The parade will, if anything, harm those women who, naively or otherwise, believe they’re supporting a legitimate effort to prevent breast cancer. Any funds raised will support a foundation that promotes what’s tantamount to snake oil for the disease.

So there is a line, in the sand… And it’s been crossed!

If I were an investigative journalist, I’d want to know more about the organization that calls itself the “Breast Cancer Natural Prevention Foundation.” Does it get tax breaks? If so, why?

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