Get Cancer. Lose Your Job?

By |April 28th, 2014

 

Let’s start with this fact: If you are employed and get a breast cancer diagnosis, it’s less likely you’ll be working at your job four years later. A newly-published study of women in Los Angeles and Detroit found that among women less than 65 years with limited-stage breast cancer, 76 percent had a paying job at the time of their diagnosis. Based on follow-up surveys of the same women four years later, the number employed was reduced by 30 percent. That’s a huge drop.

The study was just published on-line in the Cancer Journal. The authors, including a corresponding and lead author in a department of radiation oncology at the University of Michigan, make a point in the paper’s title, Impact of Adjuvant Chemotherapy on Long-Term Employment of Survivors of Early-Stage Breast Cancer, that chemotherapy may be to blame. And there’s some truth in this. Chemotherapy causes fatigue and, occasionally lasting problems such as neuropathy, heart weakness and chemobrain that might limit or impair a person’s capacity to work effectively.

On the other hand, the likelihood of developing many of those chemo-related effects depend on the dose and regimen selected. Radiation, often, causes fatigue, and – when administered to the chest, can cause premature heart disease (atherosclerosis) and lung problems, besides secondary tumors as a late consequence of treatment. It happens, though, that hormonal treatments, like Tamoxifen, can cause chemobrain too.

As someone trained to give chemotherapy, I’ll point out that none of these options for adjuvant treatment (what’s given to patients with limited disease to lessen the likelihood of recurrence) is a walk in the park. Each bears the potential for short and long-term toxicity. So I don’t blame chemotherapy in particular, although the study authors emphasized that as a culprit based on a low-level statistical correlation.

More broadly –

This news comes as no surprise. I know too well how women at work may be treated after a breast cancer diagnosis. I am privy to the stories of dozens of women who say they were unduly turned down for promotions or good assignments, opportunities…Upon returning to work, if they took time off (which some didn’t, such as your author, during her BC treatment), they  – if they take pride in their work – find themselves missing their own doctors’ appointments, exercise and other aspects of survivorship care, just to “prove” that they’re still valuable to their office, team, business.

The harsh reality is that people who have had cancer treatment are sometimes perceived as a burden on a working group: a consultant who can’t travel quite so much, a sales rep who looks less beautiful, a nurse who has to take an occasional half-day off for a check-up. Some bosses worry, although you’d be hard-pressed to find this in writing, that an employee who had cancer treatment may suffer a recurrence, and so she can’t be counted on – no matter how capable and motivated she may be – to lead a fellowship program, or to complete an ambitious project.

What would help is for doctors to guide patients with more nuanced advice, to avoid over-treatment. And patients should ask their physicians, based on their circumstances, for the least therapy that makes sense based on the size and molecular details of their tumor, to avoid long-term toxicity. And for employers to treat their workers who have illness – and not just breast cancer – as potentially valuable workers, contributors, over the long haul.

 

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JAMA Review on Mammography Points to the Need for Better Ways to Advise Women and Detect Breast Cancer

By |April 2nd, 2014

It’s hard to argue with the findings and conclusions of a new paper in JAMA put forth by Drs. Lydia Pace and Nancy Keating, both physicians with public health degrees and appointments at Harvard-affiliated hospitals. The article, published on April 2, has generated a predictable round of headlines along the lines of “Large Study Finds Little Benefit in Mammography.”

You might, while reading or hearing about this news, wonder about the value of yet another study on breast cancer screening. And you might, if you are following this blog, wonder why I remain convinced that mammography – when done right – has the potential to save many women’s lives and, what’s more, to spare even more from the physical, financial and emotional toll of prolonged treatment for advanced-stage disease.

Why I still think that breast cancer screening is a good idea for most middle-aged women (selected, from a longer list):

1. Several valid studies, most notably that from Sweden, have shown a significant survival benefit of breast cancer screening over the long term. These findings, which demonstrated a benefit to women screened in their forties, received little attention in the news.

2. Mammography is not all the same. It’s not a simple, black-and-white or numeric readout. The “result” depends a lot on the radiologist who interprets the images. Some radiologists, by their training and expertise, deliver lower false positive rates and higher true positive (malignant) “pickup” rates. To say that mammography doesn’t work, based on studies over a population, discounts the potential (and likely) benefit of having the procedure done by experts.

3. Pathology methods have improved over the past three decades. Some doctors, including epidemiologists and PCPs, may not be aware of new tools for evaluating tumors that lessen the risk of over-treating early-stage and indolent tumors.

4. Longer survival is not the only benefit of mammography. Late detection involves risks, and costs. “Screening neglect,” as some researchers call it, adds intensity to needed treatment when patients first seek care for advanced disease. This was the focus of a recent paper in the American Journal of Roentgenology that got little press except for the Cleveland Plains Dealer. The investigators in that careful but retrospective analysis found that among women in their forties, breast cancers detected in routine mammograms were significantly smaller than those detected in women who waited until they felt a lump or had symptoms. That finding was no surprise. But what mattered is that the difference in size of invasive breast cancers found – between screened and unscreened women – translated to less chemotherapy for those screened. The point: finding breast cancer early can reduce the need for toxic and costly treatment.

In reading the new JAMA paper, “A Systematic Assessment…” it seems like the authors are giving a well-prepared talk. Essentially it’s a review of reviews on mammography. Yes, it’s that “meta.” They examined the literature on mammography, going back to 1960 – but with an appropriate emphasis on more recent studies, to address 4 (huge, complex) questions: 1) what is the benefit of mammography screening, and how does it vary by patient age and risk?; 2) what are the harms of mammography screening?; 3) what is known about personalizing screening recommendations?  4) how can patients be supported to make more informed decisions about screening?

This is an ambitious set of questions, to say the least. The tables provided, which are for the most part inconclusive, draw heavily on findings that vary in the era of data collected, methods of analysis, and reasonableness of authors’ assumptions, i.e. validity.

But there is no news on mammography here, except that these two thoughtful investigators carefully reviewed the literature. There are no original data in this ambitious analysis, i.e. there is no new information about mammography’s effectiveness, the false positive rate, the harms of screening, overdiagnosis, etc.

Unfortunately the article, at a glance, may add to the growing perception among journalists, primary care physicians who may not read below the paper’s title, and others – including many ordinary women – that mammography’s effectiveness has been, again, disproved.  And so if journalists cover this “story,” as they have and will, our collective memory will incorrectly recall another negative finding, which this is not.

The authors’ main conclusions are that decision aides may be helpful, and that developing better ways of screening for breast cancer would be even better than that. I agree.

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Old and New Music, on Dying to Give Birth

By |January 5th, 2014

Recently I saw Inside Llewyn Davis, the new Coen brothers’ film about a folksinger in Greenwich Village. The moving, fictional story takes place in the early 1960s. The protagonist, handsomely portrayed by Oscar Isaac, can’t quite make it as a musician. He roams from one friend’s apartment to another, never quite sure where he’ll go next. There’s a lot you might explore, intellectually, about his journey, a cat named Ulysses and a trip to a Chicago club called the Gate of Horn.

I liked this sad movie, a lot.

What I nearly missed, though, was the significance of one of the songs, “The Death of Queen Jane.” Fortunately an obstetrician-gynecologist and neighbor, Dr. Peggy Polaneczky, reminded me by her post on its relevance to women’s health. The English ballad tells of Jane Seymour, a wife of Henry VIII. She died in October 1537, at less than 30 years of age, days after delivering a male heir. Queen Jane’s labor was prolonged, her death attributed to complications of childbirth.

Image of the actress Carey Mulligan, Inside Llewin Davis

The actress Carey Mulligan, Inside Llewin Davis

Fast-forward 475 years and a bit more…

In 2012, the WHO reported that approximately 800 women die each day from preventable causes related to pregnancy. That figure translates to over 300,000 unnecessary deaths each year, worldwide. Pregnancy-related deaths declined sharply in the United States and most of the world in the 20th Century. The CDC indicates that U.S. maternal death rates have been on the up since 1987. The reasons for this trend are not established. That some are having children at an older age may be a factor. But most pregnancy-related deaths in occur in young women. The problem is particularly grave among African Americans. Likely contributing risks, from 1987 to 2009, include lacking of access to health care, and having chronic medical conditions like diabetes, hypertension and obesity.

Shifting notes -

The music Inside Llewyn Davis is lovely, haunting. Seeking details on the traditional English folksong, “The Death of Queen Jane,” led me through a different sort of journey. Here’s a link to some information on it from the Mainly Norfolk English Folk and Other Good Music ProjectOn YouTube you can find versions performed by Joan Baez, among others. Wouldn’t you know it, the music of her sometimes lover, Bob Dylan, plays toward the closing of the Coen brothers’ film? Dylan has a song, “Queen Jane Approximately,” that was picked up by the Grateful Dead. The consensus on Wikipedia, though, would suggest that Dylan’s lyrics have nothing to do with the Tudor Queen.

At that point I stopped searching for answers about Jane Seymour’s cut life, whether she was in labor for two or nine days, and the meaning of the song. And I’ll close with this sound clip of “The Death of Queen Jane” from Inside Llewyn Davis, performed by Oscar Isaac. You can catch a fragment of the desperate woman’s plea.

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Talking About Physician Burnout, and Changing the System

By |August 23rd, 2012

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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Harsh Words, and Women’s Health at Risk

By |March 6th, 2012

I’ll open with a confession –

Women’s health has never really been at the heart of ML. Your author has, historically, relegated subjects like normal menstruation, healthy pregnancy and reproduction and natural menopause to her gynecologist friends. Sure, I learned about the facts of life. I even studied them in med school and answered questions, some correctly, along the way. By now, I’ve lived through these real life-phases directly. But these topics never drew me. That’s changed now.

Women’s care – and lives, in effect – are jeopardized on three fronts:

First, on birth control. Last week the Senate narrowly tabled a move to limit insurers’ responsibility to cover contraception. The vote on the so-called “conscience” amendment was 51-48. What this tells us is that essentially half of that powerful group either agrees with limiting women’s access to birth control or sees it as dispensable in the context of political aims.

The very fact that the proposal reached the Senate floor is disturbing. Without access to birth control, women –  including teenagers, people with significant medical problems that can be exacerbated by pregnancy, those who can’t afford to feed another child, and some who are already troubled or otherwise might not be ready or prepared to have children – are much more likely to become pregnant. It shouldn’t take a doctor to articulate this obvious point, and I can’t understand why so many are silent on it, but since so few physicians and the AMA in particular hasn’t issued any statement on this, I’ll stick my neck out and say it clearly: Lack of contraception puts women and their conceivable future-kids at risk for health problems that could be avoided.

The language surrounding the amendment is problematic, besides. Who are the anti-birth control legislation-writers to imply that “conscience” is involved in withholding contraception, and not the other way around? It’s like the “pro-lifers” who’ve implied that the rest of us aren’t.

Second, on access to safe abortions. I respect that some people think it’s wrong to terminate a pregnancy. But I also know that plenty of women, especially young women, get pregnant who don’t want to be pregnant. Regardless of who’s “responsible” – and any reader of this blog knows I’m no sucker for finger-pointing and behavior blame games – the bottom line is that if abortions become out-of-reach, women will suffer hemorrhage, life-threatening infections, permanent infertility  and premature deaths.

Hard to know how many women had ill effects or died from botched abortions before January, 1973, when the Supreme Court issued its decision on Roe vs. Wade. Like most women of my generation, I know of those unfortunate outcomes only indirectly. Still, I can’t rid my brain of the scary, unclean place Natalie Wood visits with a wad of cash in the 1963 movie Love with the Proper Stranger, or the tragic outcome when actor Gael García Bernal takes his pregnant love to an abortionist in the film Crime of Padre Amaro, set a decade or so ago in Mexico. But the real scoop comes from older physicians and nurses, here and now. When I was in med school in the 1980s, they told me stories of women and girls showing up in the emergency room bleeding, pale… dead.

As outlined by editorialists and writers elsewhere, mergers of Catholic hospitals with other medical centers threaten to reduce or eliminate access to abortions in some rural areas. In states like Texas, the physical and emotional rigmarole to which pregnant women are subjected prior to an abortion – including mandatory listening to a description of the fetal organs and a discussion loaded make what might be a tough decision unbearable, especially if the woman lacks confidence.

Which leads me to the third point of vulnerability - that women should be able to obtain care without intimidation or emotional abuse.

When Rush Limbaugh spoke last week, he wasn’t just talking about one Georgetown Law student. He was speaking to and about millions of young women who are sexually active. He called them sluts and insinuated they are like prostitutes. Adding insult to verbal injury, he said he’d like to watch videos of the sex. You could say who cares, he’s just some right-winged showman blowing off steam and misogyny. But this is a man who speaks to conservative leaders and feeds ideas to many households in America. Scary that the Republican front-runners, men who would be President of the United States next year, didn’t call Rushbo out. Rather, they let it go. As they might your daughter’s health, or access to birth control, or to a safe abortion.

In this new climate of shame, it’s easy to imagine a girl in some communities might feel really, really bad about herself simply for being sexually active. Whether she’s 17 years in high school, or 21 years in college, or 25 and maybe a department store clerk – and possibly lonely or confused – she may be embarrassed to ask for birth control. The Scarlet C, Robert Walker aptly called it yesterday.

The paradox is that this kind of rough talk, posturing and in some states, puritanical law-making, make it more likely that a sexually active young woman will become pregnant. And if she does become so, now, she may delay seeing a doctor because she fears his or her moral judgment about her behavior. And that leads to less healthy outcomes, and more deaths – fetal and maternal.

This is a serious health issue. I wish more doctors would speak out about it.

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Komen Update – Future Plans?

By |February 3rd, 2012

As many ML readers are aware, late this morning, the Susan G. Komen Foundation announced it will not cut current grants or funding to Planned Parenthood. This reversal comes as welcome news to those who support the agency and its work. The New York City branch issued this statement.

Still, many breast cancer advocates, activists and others question Komen’s priorities. This episode draws attention to debate within the BC community about the relative merits of spending charity dollars on screening, education, awareness, research and other concerns.

The long-term fallout from this week’s news and the agency’s reversal aren’t known. As I suggested earlier, Komen’s leadership might take this opportunity to reassess its mission and goals.

—-

 

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A Note on the Komen Fiasco

By |February 3rd, 2012

When I first heard the Susan G. Komen Foundation is nixing its financial support of Planned Parenthood, I thought it might be a mistake. Maybe a rogue affiliate or anti-choice officer had acted independently of the group’s core and mission, and the press got the early story wrong. I waited for Nancy G. Brinker, Komen’s surviving sister, to step in and deny the BC agency’s change of plans. That didn’t happen.

Rather, in a stilted video released yesterday, Brinker defends her agency’s decision as part of a “strategic shift” having to do with funding for any organization under investigation. That’s a bogus excuse, as others have detailed.

Komen, the world’s largest BC agency, has been under scrutiny for some time. Through its early fundraising campaigns and walks, the group raised public awareness – and discussion – of the disease. Since its inception in 1982, the agency has invested over $1.9 billion in education, breast-cancer screening, research and other grants. The discourse has changed, though. Now, many are critical of Komen’s historic focus on BC education and screening, including mammography, and tire of seeing so much pink.

This week’s outcry over the agency’s political turn has been fierce. It’s not too late for Komen’s leadership to take note, change course and revise its agenda.

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The Iron Lady, a Film About an Aging Woman

By |January 30th, 2012

image, "the Iron Lady"

Over the weekend I saw the Iron Lady, a movie about Margaret Thatcher, the former Prime Minister of England.  I expected a top-notch, accented and nuanced performance by Meryl Streep, and got that.

The film surprised me in several respects. It’s really about aging, and how a fiercely independent woman withers. The camera takes you within her elderly, blurry, husband-conjuring mind. She’s forgetful and rambling, but maintains an interest in current events, and ideas. She looks back on events in her life with pride and, seemingly, some regrets.

Well done, worth seeing!


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Visiting the Scar Project Exhibit

By |November 7th, 2011

On Friday I visited the Scar Project exhibit at Openhouse, on Mulberry Street just south of Spring. Photographer David Jay offers penetrating, large, wall-mounted images of young people with breast cancer.

The photos reveal women who’ve have had surgery, radiation, reconstruction or partial reconstruction of the breasts. Some are strikingly beautiful. Some appear confused, others confident. Some look right at you, defiant or maybe proud. Some, post-mastectomy, adopt frankly or strangely sexual postures. Others hide a breast, or turn away from the lens.

This collection is not for everyone. The photos of ravaged bodies of women with cancer might be upsetting, if not frankly disturbing, to some who look at them. Not everyone chooses to do so.

The women’s scars and expressions are telling. Though not representative, these images reflect wounds not often-shown in medical journals, or elsewhere.

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NEJM Publishes New Review on Breast Cancer Screening

By |September 26th, 2011

With little fanfare, the NEJM published a feature on breast cancer screening in its Sept 15 issue. The article, like other “vignettes” in the Journal, opens with a clinical scenario. This time, it’s a 42 year old woman who is considering first-time mammography.

The author, Dr. Ellen Warner, an oncologist at the University of Toronto, takes opportunity to review updated evidence and recommendations for screening women at average risk for the disease. She outlines the problem:

Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and an estimated 458,000 deaths reported in 2008.(1)

On screening:

The decision to screen either a particular population or a specific patient for a disease involves weighing benefits against costs. In the case of breast-cancer screening, the most important benefits are a reduction in the risk of death and the number of life-years gained….

She breaks down the data for mammography by age groups:

For women between the ages of 50 to 69 the evidence is clear, she says. For those over 70, there are little data to support breast cancer screening. There’s a consensus that screening isn’t appropriate for women with serious coexisting illnesses and a life expectancy of less than 5-10 years.

For those between the ages of 40-49, Warner challenges the revised 2009 USPSTF recommendations on several counts. She critiques those authors’ weighting of data from the Age trial of 161,000 women, emphasizing the use of an antiquated (single view) mammography technique and flawed statistics. She considers:

…However, this change in remains highly controversial,22, 23 especially because of the greater number of years of life expectancy gained from preventing death from breast cancer in younger women. According to statistical modeling,19 screening initiated at the age of 40 years rather than 50 years would avert one additional death from breast cancer per 1000 women screened, resulting in 33 life-years gained.”

What I like about Warner’s analysis, besides its extreme attention to details in the data, is that she’s not afraid to, at least implicitly, assign value to a procedure that impacts a young person’s life expectancy relative to that of an older person.

She goes on to consider digital mammography and the Digital Imaging Screening Trial (DMIST [NCT00008346]) results. For women under 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).

The article is long and detailed; I recommend the full read including some helpful tables, with references to the major studies, and charts.

In concluding, the author, who admits receiving grant support from Amersham Health (a GE subsidiary), consulting fees from Bayer and lecture fees from AstraZeneca, returns to the hypothetical patient, and what might be said to a woman in her 40s who lacks an outstanding risk (such as a genetic disposition or strong family history):

…Mammography screening every 2 years will find two out of every three cancers in women her age, reduce her risk of death from breast cancer by 15%. There’s about a 40% chance that further imaging (such as a sonogram) will be recommended, and a 3% chance for biopsy with a benign finding….

In my opinion (ES) this is key – that the chances of a false positive leading to biopsy are only 3% for a woman in her 40s. If those biopsies are done in the radiology suite with a core needle, every 2 years for women of average risk, the costs of false positives can be minimized.

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1 in 70 Women Develops Breast Cancer Before Reaching 50 Years

By |September 16th, 2011

A post in yesterday’s Well column, about coverage of breast cancer by the media, focused on the first-person narrative of NBC’s Andrea Mitchell. Journalist Tara Parker-Pope writes:

Her announcement has generated much discussion in the blogosphere, including an analysis by Gary Schwitzer, publisher of HealthNewsReview.org, who writes that Ms. Mitchell made some missteps in discussing her cancer.

The Times column goes on to consider what was said, and how it might have been said better, and I agree with much of it. But mainly it’s a meta discussion, journalists talking about how other journalists consider breast cancer facts, figures and narratives.

Buried deep is this number, that according to the NCI, one in 69, or for the sake of simplicity – approximately 1 in 70 – women in the U.S. will receive a diagnosis of BC in her forties. That is an astonishingly enormous proportion of women under 50 years affected by a devastating disease.

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Should You Tell Your Employer When a Loved One Is Ill?

By |September 12th, 2011

An article caught my attention in the September AARP Bulletin:

The Caregiver’s Dilemma considers the 61.6 million people in the U.S. who care for older relatives or friends. People with jobs are, understandably, unsure if they should let their boss or supervisor know they’re caring for someone who’s sick. This indirect cost of illness and aging in America is said to tally $33.6 billion each year.

The pressure on workers is tough, writes Sally Abrahms:

Many employees are in that elder care-giving boat, yet workers with work-family conflicts are often reluctant to raise the issue with superiors. They fear they’ll be viewed as not committed enough, or receive bad year-end reviews. They may also think that discussing their personal life is unprofessional or sense resentment from colleagues and the boss, who may have to pick up the slack during their absences…

The article reminded me of the dilemma faced by cancer patients, and by the parents or children of anyone who’s got a serious diagnosis and needs help. How much to tell the boss?

It’s a tough economy.

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Medical Aspects of ‘The Help’: The Plight of a Woman with Recurrent Miscarriages

By |September 8th, 2011

the character Celia, in "The Help"

Last weekend I saw The Help, a movie on race relations in Jackson, Mississippi 50 years ago with lingering implications for people who hire “help” to take care of their children and tend to their personal business anywhere in the world, including now. It’s a heavy-handed, simple-message and nonetheless very enjoyable film, with fine acting and imagery, based on the book of the same title by Katherine Stockett.

One element of the narrative interested me from the medical perspective, having to do with the plight of a pale, thin and sexy young woman who’s marginalized by the white Jackson social elite. The character Celia, portrayed with flair by Jessica Chastain, lives, isolated, on an out-of-town plantation. She spends her days alone while her husband’s at work. The nominally proper women in town, while playing bridge and otherwise gathering, call her “white trash,” and she sometimes lives up to their prejudices by drinking too much and behaving erratically.

It turns out the young woman’s having a hard time because she’s unable to bear children. She feels inadequate and fears her husband might leave her if he found out. Her history of recurrent miscarriages is discovered by the African American maid, Minny, who comes to work with her. In a revealing scene Minny finds Celia locked in the bathroom, severely bleeding from a miscarriage and crying. The maid, played with conviction by Octavia Spencer, helps her to recover, clean up, and bury the fetus in a shoebox in the yard, nearby three other small burial sites. With this, the young woman’s odd behavior becomes comprehensible.

I couldn’t help but think of countless women of earlier eras, and friends I’ve known in my adulthood, and women I’ve treated as a physician, who felt really bad about their inability to bear children. These days, with fertility treatments and work-ups for miscarriages so prevalent in communities like mine, we don’t see so many cases like Celia’s. It used to be a common problem, and it still is in many regions in the U.S and certainly in other parts of the world, for women who have difficulty conceiving or carrying babies to term, not just to not have children, but to become sad, and feel inadequate about themselves as women.

The Help is a worthwhile film at many levels, with fine acting, a good, PC message and story. I hope movie-goers will take special note of Celia’s predicament.

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Notes on Kris Carr and Crazy Sexy Cancer

By |August 15th, 2011

I’m half-tempted to put down yesterday’s new NYT Magazine feature on crazy sexy cancer goddess Kris Carr. Her blog was one of the first I found when I started ML, and it was the most popular link on my fledgling site until I pulled it, fearful of somehow sponsoring a too-alternative oncology perspective.

But I give Carr credit, sincerely: Crazy Sexy Cancer is a lot more appealing a title than, say, Medical Lessons. I’d read CSC, for sure, if I had a new diagnosis or, maybe, if I were alone and bored or suffering from a condition like chronic fatigue syndrome or insomnia and hadn’t gone to med school. Even for people who really have cancer, letting loose and being attractive sounds, well, like a lot of fun.

Kris Carr has played her C-card like a Queen of Diamonds. You go, girl!

So this morning I pulled a hard-cover edition of Cancer: Principles and Practice of Oncology, 7th Edition (2005; Lippincott, Williams & Wilkins; edited by DeVita, Hellman and Rosenberg) off my shelf and looked up Carr’s stated disease, epithelioid hemangioendothelioma. Being the old-fashioned woman that I am, I read about EH* in print. Only then did I discover a handy, unopened CD housed inside the cover of the “oncology bible,” as we used to call this text.

the editors, 'Cancer: Principles and Practice of Oncology,' Lippincott

DeVita and his colleagues classified this condition as a vascular tumor in a chapter on sarcomas, in a section on tumors that develop in smooth muscle. Now, at risk of boring my readers with the medical “scoop” on this strange and sometimes benign-behaving sarcoma variant:

As its name implies, epithelioid hemangioendothelioma is an angiocentric vascular tumor with metastatic potential…These lesions may appear as a solitary, slightly painful mass in either superficial or deep soft tissue. Metastases to lung, regional lymph nodes, liver, and bone are reported. Another pattern is that of a diffuse bronchoalveolar infiltrate or multiple small pulmonary nodules. This entity has also been called IBVAT…can also arise in the liver, often presenting as an incidental finding or as part of a workup for mild elevation of liver enzymes or vague abdominal pain. Multiple liver nodules are the rule. Although these lesions can metastasize, they usually run an indolent course. Liver transplantation has been performed…

This sounds scary, sure, but the bottom line is that this tumor falls into unchartered oncology territory because they’re so rare. As reported in the Times piece there are only 40-80 cases per year in the U.S. A reference in the textbook, above, leads to a 1989 report in the American Journal of Surgical Pathology. In that study of 10 cases, the authors describe an unpredictable course for the disease.

As told by Mireille Silcoff in the magazine, EHE comes roughly in two forms: one’s aggressive and one’s not. So what the oncologist at Dana Farber suggested – that she go about her life, and “let the cancer make the first move” – was a reasonable strategy, one that allowed them (patient and doctor) to find out, over time, what would be the nature of her particular EHE.

Carr lucked out: She has the “good EH” as Larry David might say. So far, at least, she’s enjoyed a  productive, enterprising  life with cancer. From the Times:

She was given the diagnosis in 2003 and rose to prominence with a 2007 documentary called “Crazy Sexy Cancer.” She subsequently wrote two successful books— “Crazy Sexy Cancer Tips” and “Crazy Sexy Cancer Survivor” — about her peppy, pop-spiritual approach to her disease, and she soon became what she sometimes describes as a “cancerlebrity” or, at other times, a “cancer cowgirl.”

Now she has a blossoming business. At the cafe, she laid it all out while sipping a coconut-vanilla chai with soy. Her blog postings are being syndicated, she has pending sponsorship contracts, her weekend workshops are thriving and she has provided one-on-one coaching sessions on Skype ($250 for 90 minutes). She also just bought a farm — 16 acres complete with two houses, a barn, a meadow and a forest…

Am I jealous? Sure, maybe, some…But I’d be hopeless on a farm.

Besides, she hasn’t received chemo, had limb-removing cancer surgery, undergone early menopause…She looks fabulous! And with that kind of cancer, maybe so would you.

The issue is that Karr runs a well-connected wellness enterprise. She sells a way of life, David Servan-Schreiber style, with the message that you can beat cancer and be well if you nourish your body and mind with the likes of 21-day cleansing diets, juiced Whole Foods and meditation-enhancing mala bead jewelry.

The danger is that readers and customers/followers may believe that her current well-being is due to her lifestyle choices. And that some people with the malignant form of EHE, whose emails she may not read, struggle with feelings of inadequacy and defeat.

So I’ve learned from Kris Carr: For one thing, I don’t think I ever saw a case of EH and she, through her story, persuaded me to look it up. Second, she’s a smart business woman, who’s turned her life around upon a cancer diagnosis. Third, (am undecided, ideas?)

And I’m taking careful notes. Let’s leave it with that, for now.

*This author prefers to call epithelioid hemangioendothelioma EH, but most sources use EHE, so I’ll abbreviate as do the sources or use my own style, accordingly.

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Wednesday Web and Shoutout: Flashfree Moves to a New Site

By |August 10th, 2011

Flashfree, a super-hip blog on menopause and women’s health, has a new home on the Web. Health writer Liz Scherer started the blog in May, 2008, upon searching far and wide for straight talk on midlife women’s health issues.

soybean (USDA image, WC)

I found Flashfree early on in my exploration of on-line health sites. Liz is sharp and serious, curious, current and funny. What I most appreciate is that she routinely supports her reports with links to relevant medical journals.

Today’s post is on soy; a new study in the Archives of Internal Medicine confirms that the proteinaceous stuff neither relieves hot flashes nor prevents bone thinning in women.

Good luck to Liz in her new spot!

I’ll be following -

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Good People, a New Play About Chance, Decisions and Fate

By |May 26th, 2011

A short note on Good People, the title of a new play at the Manhattan Theatre Club starring Frances McDormand

It’s a simple story, at some level, about a middle-aged woman from south Boston who loses her job. She has a disabled, adult daughter who needs caregiving, and she needs money. She contacts some old friends, and scours the neighborhood for a job. She encounters a once-boyfriend, just for a summer at the end of her childhood, who’s become a doctor with a fancy office and a fancy house and a beautiful wife.

Frances McDorman, in a photo for the MTC

And she’s angry, angry because she’s never been able to leave her community despite, as she puts it, “being nice.” She put her daughter’s needs first and helped others when she could – or so she says, but she was too often late for work at one job and the next, because she was waiting for the daughter’s sitter, or because she couldn’t pay the bill on her car, or for some reason or other unfortunate event, as she sees it, that isn’t quite her fault.

The play’s well-executed, with firm acting and revealing details – like the wallpaper and mismatched furnishings  in the woman’s kitchen, and the spotty sportswear the women don when they go out to be sociable. Some scenes take place in a church, where the characters chat as they play “BINGO,” waiting and hoping for a lucky break.

It’s about fate, and responsibility, and assumptions people sometimes make. And it’s closing this Sunday.

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Confusing Reports On Coffee and Cancer, and What To Do About Breakfast

By |May 16th, 2011

When I was a medical resident in the late 1980s, we treated some patients with pancreatic cancer on a regimen nick-named the coffee protocol because it included infusions of intravenous caffeine. How absurd, we thought back then, because years earlier caffeine had been linked to pancreatic cancer as a possible cause.

Now, two new studies suggest that coffee consumption reduces a woman’s risk for developing breast cancer, according to MedPage Today:

Women who drank at least five cups of coffee daily had a significantly lower risk of postmenopausal breast cancer, an analysis of two large cohort studies suggested.

…Coffee has a paradoxical relationship with breast cancer risk. The beverage’s complex mix of caffeine and polyphenols suggests a potential to confer both carcinogenic and chemopreventive characteristics, the authors noted…

I’m incredulous, still.

As with most compounds we ingest or otherwise absorb, it’s conceivable that caffeine could damage some cells or somehow factor into some tumors’ growth just as it might suppress others, and that the dose matters. The fact is that, like most dietary chemicals, we really don’t know much about its specific effects on any cancer type.

This morning, as usual, I had an early cup of joe with low-fat milk stirred in. I might have a second cup, or a cappuccino with skim milk and cinnamon, in the afternoon. And that’s about it.

When I’m not sure if something’s good or bad for me, or both, I take it in moderation, if at all, if I choose.

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New York City Reports Long Delays for Mammograms

By |May 6th, 2011

A recent audit of nine NYC’s Health and Hospitals Corporation found City Comptroller Liu described as dangerous delays in women’s health care. It takes too long for women to get screening and diagnostic mammograms.

The 2009 audit found women at Elmhurst Hospital had the longest waits – 50 working days (that would be 10 weeks, i.e. 2.5 months) for diagnostic mammograms, on average. You can find more details here.

According to the Times’ coverage:

Ana Marengo, a spokeswoman for the city’s Health and Hospitals Corporation, which runs the public health system, said that the comptroller’s data was outdated…

At Elmhurst, she said, the wait as of December 2010 was 20 days for screening and 23 days for a general diagnostic test, as opposed to an urgent one.

Still, at Queens Hospital Center, the wait for a screening test was 56 days in December <2010>, Ms. Marengo said. “It’s due to volume and higher demand,” she said. “We only have a certain amount of resources.”

From the comptroller’s press release, a statement from Alice Yaker, Executive Director, of SHARE: Self-help for Women with Breast or Ovarian Cancer:

“While controversies about efficacy surround the screening of healthy women, there is no controversy about the need for a diagnostic mammogram in a woman who presents with a lump in her breast, for example. This requires our urgent attention, budget cuts and hospital closings notwithstanding.”

The comptroller’s message says there’s no guideline for how soon a woman with breast cancer symptoms, such as a lump, should receive a diagnostic mammogram. For screening, guidelines suggest the wait be no longer than 14 days for an appointment.

This blogger’s vote: set up a maximum wait time for diagnostic mammography: 10 working days.

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Noting Depression in Susan Glaspell’s 1917 Story: A Jury of Her Peers

By |May 5th, 2011

Recently I read the short story, A Jury of Her Peers by Susan Glaspell, with a group of women in my community. The author, with whom I wasn’t previously familiar, first reported on the real 1901 trial of Margaret Hossack, as a journalist writing for the Des Moines Daily News. Later she adapted the story as a one-act drama, Trifles, and then in 1917 as a short narrative published in Everyweek, a long-defunct magazine of the Crowell Publishing Company.

Original performance of "Trifles," (from the Billy Rose Theatre Collection, New York Public Library at Lincoln Center)

There’s a lot you might take from this swift, rich read. It goes like this: A man and his son came upon a couple’s house in rural area. The man’s been killed, clearly; his wife sits in a chair, oddly, and can’t say what happened to her husband. The local authorities and a few neighbors step in. The home was not well-kempt; the wife is accused of murder. Two other women, whose words spin the tale, poke about the kitchen and make inferences about the jailed woman’s circumstances.

Some points are readily gleaned: on homemaking, and quilting – literally and metaphorically, in early 20th Century America. There are legal elements, and allusions to domestic violence and abuse. What intrigued me most, though, was the author’s indirect depiction of their neighbor’s isolation and apparent depression:

“A person gets discouraged–and loses heart,” one considers…

“I stayed away because it weren’t cheerful–and that’s why I ought to have come,” says the other.

The two women express sympathy for the accused wife’s plight; they regret that they didn’t visit or otherwise help her earlier on, before the situation took a catastrophic, violent turn. The women understood, without saying it exactly. Mental health wasn’t a topic of common discourse, then, but these characters – and so must have the author, clearly – got the drift.

I won’t tell the whole story here, but I do recommend the tightly-woven, knotted piece.

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New Study, Presented at a Meeting of Breast Surgeons, Supports that Mammograms Save Lives of Women in Their 40s

By |May 2nd, 2011

The American Society of Breast Surgeons held its 2011 annual meeting in D.C. from April 27 – May 1. Among the papers presented was Abstract #1754: “Mammography in 40 Year Old Women: The Potential Impact of the U.S. Preventative Services Task Force (USPSTF) Mammography Guidelines.” You can find the press release, followed by the abstract, here. The main result was that screening women ages 40-49 by mammography was associated with finding smaller tumors, with less spread to the lymph nodes, than clinical breast exams alone, and this correlates with improved survival at 5 years.

The study, put forth by a group at the University of Missouri-Columbia in Columbia, MO, is  based on a 10-year retrospective chart review, from 1998 – 2008, of 1581 women treated for breast cancer at that institution. In this author’s opinion, a retrospective, chart-review type analysis of a medical intervention is about as low as you can get on the quality-of-data scale in a medical study. And, as emphasized by Dr. Otis Brawley, chief medical officer of the ACS as quoted in HeathDay’s report on the matter, these are tentative findings, presented in abstract form at a meeting. He suggested that the 5-year follow-up is too short.

That said, I think the findings are significant and likely reflect what happens when mammography screening is done right, which is that it saves lives in women 40 and older.

The results focused on the 320 women – 20% of all those treated for breast cancer at the institution – between the ages of 40 and 49 at the time of breast cancer diagnosis. Among those, mammography detected the tumors in just under half (47%) of the cases; in 53%, there was a palpable mass – the “clinical detection” group. In those with cancers were detected by mammography, the average tumor size was 2 cm in diameter; in the clinical detection group, the average size was 3 cm. (From an oncologist’s perspective that’s a huge difference; for most breast cancer subtypes that 1 cm difference in diameter portends a distinct prognosis.) What’s more, the frequency of lymph node involvement in the clinical detection group was 56%, more than twice that in the mammography group (25%), another prognosis-changer. These findings were highly significant from a statistical perspective, with p-values <0.0001.

The researchers confirmed that negative lymph nodes and smaller tumors were associated with longer survival. They estimated that disease-free survival, at five years, was 94 percent for women under 50 who received mammograms and 78 percent for those who did not receive the screening exams. Five year overall survival rates for each group were 97% and 78%, respectively.

These figures have huge implications, especially if you multiply the potential survival benefit – on the order of 20 percent at 5 years, or greater, depending on how you look at it – across over some 21.5 million women in the U.S. between the ages of 40 and 50, approximately 1.5 in 1000 of whom will be found to have invasive BC per year.*

Reuters ran this story on April 29  as did HealthDay. Both ran quotes by Dr. Paul Dale, chief of surgical oncology at the University of Missouri School of Medicine and lead author of the abstract. The findings suggest that adherence to the updated U.S. Preventive Service Task Force (USPSTF) guidelines, which do not recommend screening mammography for most women between the ages of 40 and 49, would lead to preventable deaths.

One thing the author of ML learned this morning is that Dr. Virginia Moyer, the new chair of the USPSTF and who is quoted in the HealthDay coverage, is a pediatrician and professor with a public health degree.

*based on U.S. Census data of 2000 and SEER data incidence (BC, all races, by age) accessed 5/2/11

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