Shout Outs

Updated 3/2017-- photos and all links removed (except to my own posts) removed as many no longer active.

Jason Shafrin, PhD, Healthcare Economist, is the host for this week’s Grand Rounds. You can read this week’s edition here.

This is a great time to be the Healthcare Economist. Not only am I hosting Grand Rounds for the first time, but Wisconsin sports are enjoying a renaissance. The Milwaukee Brewers are in the NLCS, the Green Bay Packers are Super Bowl Champs and undefeated, and the Wisconsin Badgers also have not lost.

How does this relate to this week’s edition of Grand Rounds? I have no idea. But I know if you’ve made it this far, you might as well take a few more minutes to review the best medical posts on the blog-o-sphere during the past week. Enjoy! ………….

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The 2011 Charles Prize for Poetry Contest deadline for entries has passed. Now while we await the announcement of the winners I hope you will enjoy reading the many wonderful entries.

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TBTAM (@tbtam) has another nice blog post on mammograms: Mammograms – Reality Check

A well-written and balanced article on mammography from USA Today may help move the conversation about this screening test away from hype and a bit closer to reality. The title – “Mammogram is ‘terribly imperfect’, though recommended.” ...

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H/T to @DrMarkham and @doctorblogs for this BMJ article by Prof Joseph Ana on this horrifying practice: Breast flattening, ironing, straightening, and pounding: a new form of violence against girls and women

Until a few weeks ago, I had never heard about the cultural barbarism of breast flattening, a native attempt to delay the development of a girl’s breasts so that they are not “attractive” to men and boys before they are ready for marriage.

Just before a girl reaches puberty her mother will (sorry but please get yourself ready to soldier on with reading this sordid topic) pass a hot instrument, usually a hot wire into the victim’s breasts or pound the victim’s breast with a pestle without any form of anaesthesia or analgesic. …..

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Runawaydoc (@runawaydoc) is a “newbie blog / pediatrician in training” who recent blog post introduces us to “the man with the golden heart.”

……As a doctor, I regret to accept that our medical system is also hijacked into this dark world. Every doctor, every lab, every pharmacist wants to extract an extra rupee. The feel of the notes satisfy more than the contentment of the patient. …….

However, in one of those social networking portals I came across a man called “Morpheus”. I was jarred with his conviction to clean the dirty waters of medicine where doctors happily waddle in. He told me that healing profession has to be cleaned, somebody has to make a move, and somebody has to start it. At the end of the day the patient should not suffer. …..

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Did you catch Radio Rounds interview of ZDoggMD? If not, you can listen to it here: Slightly Funnier Than Placebo

This week features the hottest hip hop hospitalist in the nation, ZDoggMD. When not making videos, ZDogg is a hospital physician working at a Bay Area academic hospital. Along with some of his fellow physicians he moonlights in medical satire writing and producing his own videos and songs, claiming to be slightly funnier than placebo. This episode is about the man behind the name as we delve deeper into the mind of ZDoggMD.

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My friend Methodical Madness uses her recent Mothers in Medicine post to encourage donation of blood products: Blood Bank Halloween.

The Blood Bank always has some pretty interesting Halloween decorations. Last year they had gel blood dripping from the top of the main door. This year I was excited to see a bloody hand at the Blood Bank blood product distribution window. The window is kind of like a fast food restaurant window - only it opens bottom to top instead of sliding sideways. I imagine it was designed in the 1960's. This morning when I went to take a photo of it for this blog that was marinating in my head, I was upset to find it missing. I wandered into the blood bank.

"Where is that bloody hand decoration that was in the window?" …………

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H/T to @scanman for this tweet: Superb collection/selection >> RT @mankuthirai: The 50 Best Short Stories of All Time

The short story is sometimes an under-appreciated art form. Within the space of a few pages, an author must weave a story that’s compelling, create characters readers care about and drive the story to its ultimate conclusion — a feat that can be difficult to accomplish even with a great degree of savvy……….

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Thanks to @glevin1 who noticed this website on Google+ and know I’d appreciate it: LUKE Quilts. Luke’s website has three main sections – about, projects, and blog. His quilts are amazing! Check them out.

Skyes’ Preventive Double Mastectomy

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

When Wanda Skyes, 47, had a bilateral breast reduction in February, the pathology returned with DCIS present in the left breast specimen.  Recently the comedian appeared on  "The Ellen DeGeneres Show" and during the interview revealed her breast cancer diagnosis and her decision to have a double mastectomy.

Sykes continued, "It wasn't until after the reduction that in the lab work, the pathology, that they found that I had DCIS [ductal carcinoma in situ] in my left breast. I was very, very lucky because DCIS is basically stage-zero cancer. So I was very lucky."

But, she added, "Cancer is still cancer. I had the choice of, 'You can go back every three months and get it checked. Have a mammogram, MRI every three months just to see what it's doing.' But, I'm not good at keeping on top of stuff. I'm sure I'm overdue for an oil change and a teeth cleaning already."

Because she has a history of breast cancer on her mother's side of the family, Sykes explained she opted to have a bilateral mastectomy.

"I had both breasts removed, because now I have zero chance of having breast cancer," she said. "It sounds scary up front, but what do you want? Do you want to wait and not be as fortunate when it comes back and it's too late?"

The American Cancer Society has a nice article which reviews the risk factors for breast cancer.  The risks factors for Sykes (which can be garnered from the news article) include a family history of breast cancer (don’t know which relative on mother’s side), a personal history of breast cancer, African-American, and age.

I don’t think I would have advised her to have a bilateral prophylactic mastectomy on this information, but perhaps with more info I would have.  Though an effort is made to remove all breast tissue with a prophylactic mastectomy, it is wrong for us doctors/surgeons to ever suggest that we actually DO get it all.  More truthful to say we have removed most (90% plus).

While we are on the topic of breast cancer, please, take a look at Elaine Schattner, M.D., Medical Lessons, post from Monday:  NEJM Publishes New Review on Breast Cancer Screening.

Related posts:

Risk Factors for Breast Cancer (October 2, 2007)

Prophylactic Mastectomy (January 28, 2009)

Women Don’t Regret Prophylactic Mastectomy (May 5, 2011)

Is Prophylactic Mastectomy Worth It? (August 2, 2011)

Media Sources

Wanda Sykes' double mastectomy is aggressive treatment for DCIS; Karen Kaplan; Los Angeles Times/For the Booster Shots blog, September 23, 2011

Wanda Sykes has double mastectomy;  Ann Oldenburg; USA Today, Sep 23, 2011

Wanda Sykes: I had a double mastectomy; Jessica Derschowitz; CBS News, Sep 23, 2011

For more information on DCIS

Breast Cancer; PubMed Health, last updated December 2010

DCIS - Ductal Carcinoma In Situ; BreastCancer.org, last updated August 12, 2011

Ductal carcinoma in situ (DCIS); Mayo Clinic, last update June 23, 2011

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

James Logan, MD is the host for this week’s Grand Rounds. You can read this week’s virtual tour edition here.

Remember the days when one accessed the internet by using a telephone line to dial up an isp? For that matter, remember when one made telephone calls using an actual telephone line? Well, for this blogger, that day has returned. I very foolishly agreed to host grand rounds during the week after a move to a new apartment (still no agreement on a new dining room table, by the way) not realizing that our high speed internet would not yet be set up during the time I would be preparing this post. No matter. I temporarily have free dial-up access! Hence, this grand rounds is going to be a tribute to Web 1.0 and the various deprecated tags of HTML 4. Comments, of course, are still enabled. ……….

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Elaine Schattner, M.D, Medical Lessons, discusses the recent news regarding mammograms in her recent post:  Mammography Update

This week I’ve come across a few articles and varied blog posts on screening mam­mog­raphy. The impetus for rehashing the topic is a new set of guide­lines issued by the American College of Obste­tri­cians and Gyne­col­o­gists. That group of women’s health providers now advises that most women get annual mam­mo­grams starting at age 40.

Why every year? I have no idea. To the best of my knowledge, there are no data to support that annual mam­mo­grams are cost-​​effective or life-​​saving for women in any age bracket at normal risk for BC. ….

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Really loved this story reported on ABC Evening News this past week:  Dog Raises Over $17,000 After Running Marathon for Cancer Research (photo credit)

In 2008, when his new family adopted him, Dozer the Goldendoodle was the only pup left in the litter.

"He was the last of the bunch," said Rosana Dorsett, Dozer's owner. "He was the dog no one wanted ... but he's got a great heart."

It made Dozer kind of an underdog. But fast forward three years to the day of the Maryland Half Marathon -- a 13-mile race for cancer research -- and this pup found his way to the front of the pack. ……

The article includes a great video.  Go watch it!

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H/T to @KentBottles  for the link to this Salon article by Mandy Van Deven:  The neuroscience of disgust

We all have things that disgust us irrationally, whether it be cockroaches or chitterlings or cotton balls. For me, it's fruit soda. It started when I was 3; my mom offered me a can of Sunkist after inner ear surgery. Still woozy from the anesthesia, I gulped it down, and by the time we made it to the cashier, all of it managed to come back up. Although it is nearly 30 years later, just the smell of this "fun, sun and the beach" drink is enough to turn my stomach.

But what, exactly, happens when we feel disgust?
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Check out LITFL weekly review of the “webbed world of emergency medicine and critical care”  -- LITFL Review 029

……… Broome Docs:  Top spot this week heads up north to Casey Parker with his brilliant take off of the hit song “If you are happy and you know it.” If you’ve just come of a weekend of dealing with drunks, punks and personality disorders your bound to be singing this all the way to your next shift. Maybe we could even use the song as a preventative health measure and play it in the waiting room? 

“If you are angry and you know it, punch a pillow.

If you are angry and you know it, punch a pillow.

Don’t punch your wife, or the fridge or a window -

If you are angry and you know it punch a pillow!

If you are sad and you know it, call a friend. ….”

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Check out DinoDoc’s post: Overkill

I saw a lady with a boil. It began as a small red bump which got bigger and harder, then drained white stuff, and was now getting better.

The reason she was worried about it was its location: it was on her breast. This was why the chief complaint officially read, “Breast lump” despite the fact that it was technically no such thing.

I examined her carefully, determining that the pathologic process was indeed confined to the skin and clinically did not involve the actual breast tissue in any way. However because she was of an age for screening mammography, I did take the opportunity to urge her to have it; which she did. The problem arrived with the radiology report:    …………..

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Tomorrow, Wednesday Aug 10th, Dr. Tony Youn will be doing a live online reading from In Stitches via Livestream at 5:30pm ET at www.livestream.com/dryoun.    There will also be a live Q&A where viewers can ask questions and get them answered by Dr. Youn in real time.  Dr. Yong blogs at Celebrity Cosmetic Surgery and can be followed on twitter:  @TonyYounMD.  (photo credit)

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I recently discovered another sewing blog:  the Dreamstress.  This post is for the sewer and the shoe lover:  Greek key shoes – swoon  (photo credit)

As we all know, I’m really into Greek keys.
My current Greek key  obsession is these evening boots:

……….I like the idea of the shoes, but really, I couldn’t handle them in person.  It’s just too much shoe for me

Is Personalizing Mammogram Screening the Way to Go?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

I read the LA Times article by Shari Roan, Study urges more individual mammogram guidelines, with interest.  As Roan notes, guidelines to date have mainly focused on a woman’s age and not her other risks factors.

The American Cancer Society recommends that healthy women undergo screening mammograms every one to two years beginning at age 40 regardless of risk factors. In 2009, the U.S. Preventive Services Task Force recommended a different schedule which urged the inclusion of an individual’s personal risks:  screening for women ages 40 to 49 should be based on individual risk factors and women ages 50 to 74 should be screened every two years.

Monday, a paper was published in the Annals of Internal Medicine (full reference below) which argues for a more personalized approach to screening mammograms.

The study by Dr. Steven R. Cummings, senior author and senior researcher at the California Pacific Medical Center Research Institute, and colleagues was based on a computer model comparing the lifetime costs and health benefits for women who got mammograms every year, every two years, every three to four years or never.

The researchers concluded that “Annual mammography was not cost-effective for any group, regardless of age or breast density.”

They also note that “Mammography is expensive if the disutility of false-positive mammography results and the costs of detecting nonprogressive and nonlethal invasive cancer are considered.”

I find it interesting that the major limitation of the paper noted by it’s authors is that the results are not applicable to carriers of BRCA1 or BRCA2 mutations.   This is a group of women who has a major risk factor for developing breast cancer, yet “personalization” of screening mammograms might not work for them.  Why not?  Might not personalization for this group involve more frequent rather than fewer mammograms?

I personally like the idea of individualizing the screening schedule, rather than one-size fits all.  It is why I have embraced the U.S. Preventive Services Task Force recommendations. 

Related posts:
New Breast Cancer Screening Guidelines (November 17, 2009)
Screening Mammogram Recommendations (January 7, 2010)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)
Dr. Marya Zilberberg’s, Healthcare, etc, post:  Why medical testing is never a simple decision (December 15, 2010)

REFERENCES

1.  Personalizing Mammography by Breast Density and Other Risk Factors for Breast Cancer: Analysis of Health Benefits and Cost-Effectiveness; John T. Schousboe, Karla Kerlikowske, Andrew Loh, and Steven R. Cummings; Ann Intern Med July 5, 2011 155:10-20

2.  To Screen or Not to Screen Women in Their 40s for Breast Cancer: Is Personalized Risk-Based Screening the Answer? (Editorial); Jeanne S. Mandelblatt, Natasha Stout, and Amy Trentham-Dietz; Ann Intern Med July 5, 2011 155:58-60

Screening Prior to Cosmetic Breast Surgery – an article review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

How are we plastic surgeons with screening prior to cosmetic breast surgery?  This article from November 2009 (full reference below)  reviews this topic.  Note this survey was done prior to the release of the new USPSTF guideline recommendations for screening mammograms the same month.   I wonder if a new survey would have different outcomes.

The article reports on a study which looked at breast cancer screening practices of American plastic surgeons (self-reported) and the degree to which those practices adhere to the American Cancer Society guidelines.

The study was conducted using an online survey of the members of the American Society of Plastic Surgeons over a 5 month period (January 2008 to May 2008). The 20 multiple-choice questions were designed to assess physician practice composition and familiarity with American Cancer Society guidelines, and to ascertain specific practices for preoperative evaluation and breast cancer screening in patients seeking aesthetic breast surgery. The survey comprised four components: general practice information, breast cancer screening practice, criteria for obtaining breast cancer screening, and criteria for further evaluation of breast cancer risk.

There were 1094 respondents (out of 4520 society members), so only a 24% response rate.   Twenty-eight responses were excluded because these surgeons responded that they do not do breast surgery, do not operate, are pediatric surgeons, are retired, or work with cancer patients only on an initial screening question.

Of the 1066 included respondents, 82% were male and 73% were in private practice.  The participants were roughly evenly distributed with respect to total years in practice, and a majority of surgeons performed augmentation mammoplasty, reduction mammoplasty, and mastopexy (96%).

In total, only 47% appeared to follow the American Cancer Society guidelines.  Only 64% claimed familiarity.

Not all responders always reviewed risk factors preoperatively in their aesthetic breast surgery patients (only 89%), nor did all responders always perform a clinical breast examination preoperatively (86%).

• 89% of respondents claimed that they obtain mammographic screening based on age
• 57% claimed to do so based on positive family history, regardless of age
• 61% stated they followed the ACS screening guidelines, 61 percent stated that they did follow the guidelines
• 24% stated that they did not know the guidelines

Seventy-five percent (n = 799) of plastic surgeons considered a mammogram within 1 year to be valid, whereas 15% (n = 166) stated that this was age dependent.

The authors concluded:

Breast cancer is a major public health problem, for which screening is at least part of the solution. Plastic surgeons are in a unique position to screen women who may not otherwise receive screening. Knowledge of the American Cancer Society guidelines is an essential component of effective cancer screening, but unfortunately only somewhat more than half of plastic surgeon respondents who perform breast surgery have knowledge of these guidelines. Being male predicted more accurate knowledge of the guidelines, but being female resulted in more aggressive screening, and possibly more diagnoses. Familiarity with the American Cancer Society screening guidelines also resulted in a greater number of perioperative diagnoses. As plastic surgeons, we have an obligation to actively participate in the health and well-being of our patients, and this involves understanding and applying good breast cancer screening practices.

Related posts:
New Breast Cancer Screening Guidelines  (November 17, 2009)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)
Screening Mammogram Recommendations (January 7, 2010)
USPSTF Breast Screening Guidelines Pushback  (January 26, 2011)



REFERENCE

Breast Cancer Screening Prior to Cosmetic Breast Surgery: ASPS Members' Adherence to American Cancer Society Guidelines; Selber, Jesse C.; Nelson, Jonas A.; Ashana, Adedayo O.; Bergey, Meredith R.; Bristol, Mirar N.; Sonnad, Seema S.; Serletti, Joseph M.; Wu, Liza C.; Plastic & Reconstructive Surgery. 124(5):1375-1385, November 2009; doi: 10.1097/PRS.0b013e3181b988c4

Screening Mammogram Recommendations

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

You may recall, in November 2009, the US Preventive Services Task Force released new recommendations on screening mammography.  Here is a summary:

• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
• The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.

For a complete discussion which I can not improve upon, check out  Dr. Margaret Polaneczky’s (aka TBTAM) post:  The New Mammogram Guidelines - What You Need to Know.

Now comes, recommendations from the American College of Radiology (ACR) and the Society of Breast Imaging (SBI).  Their guidelines for screening mammography are published in the January issue of the Journal of the American College of Radiology.  Their recommendations do not agree with the US Preventive Services Task Force.

The ACR and SBI recommendations:

• Screening mammography should begin at age 40 for women with average-risk of breast cancer.
• Women at higher-risk should begin by age 30, but no sooner than 25.
• Women who have at least a 20% lifetime risk of breast cancer, on the basis of family history, also should begin annual breast MRI by age 30, in addition to annual mammography.
• Breast ultrasound may also be recommended in addition to mammography for high-risk women and those with dense breast tissue that is often difficult to assess by conventional mammography

Women and their doctors can use assessment tools to calculate  individual risk for breast cancer.  The most commonly used risk assessment tool is the Gail Model which can give your individual risk of being diagnosed with breast cancer in the next 5 years.

Breast cancer causes about 4,500 deaths annually in women ages 40-49, and is one of the leading causes of death in women in this age group.

New Breast Cancer Screening Guidelines

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Yesterday,  the U.S. Preventive Services Task Force’s announced it’s new recommendations for Screening for Breast Cancer (November 2009).  The uproar has been loud and mostly against. 
The summary of the USPSTF’s recommendations:

• Recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
• Recommends biennial screening mammography for women aged 50 to 74 years.
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
• Recommends against teaching breast self-examination (BSE).
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.

If you recall some of the recent discussions regarding over-diagnosis  of breast cancers and the resulting harm done by the increased radiation, biopsies, and surgeries then it is easier to understand the task forces conclusions.  There has been an estimated 52% over-diagnosis of breast cancer in a populations of women who are offered organized mammography screening.  That amounts to one in three breast cancers being over diagnosed.

My personal feeling is that anyone with a family history of breast cancer should begin getting mammograms at 10 years earlier than the age when their mother was diagnosed with breast cancer.  There will always be “outliers” like the 10 year girl diagnosed with breast cancer. 

I do not agree with not teaching breast self-examination.  I think every woman/man should be familiar with their bodies.

Here are links to some of the responses to the USPSTF’s recommendations.  Some of the comments are as enlightening as the stories.

• Response of The American College of Obstetricians and Gynecologists to New Breast Cancer Screening Recommendations from the U.S. Preventive Services Task Force, November 16, 2009
• M. D. Anderson Maintains Mammogram Recommendations, November 16, 2009
• Will patients accept the new, evidence-based, breast cancer screening guidelines? by KevinMD, November 17, 2009
• Does number needed to treat help with rational decision-making? by Marya Zilberberg, November 17, 2009
• Panel Puts Off Mammography until Age 50; MedPageToday, November 16, 2009
• Mammography Screening: Are the New Guidelines Rationing by Dr Susan Love, November 16, 2009
• USA TODAY Forum: Breast cancer survivors sound off on new mammogram advice, moderated by @LizSzabo
• Susan G. Komen for the Cure® Recommends No Impediments to Breast Cancer Screening, November 16, 2009
• Breast Self-Examinations: What’s Wrong With Them? by Shirley S. Wang; Wall Street Journal Blog; November 16, 2009
• Breast-Screening Advice Is Upended by Shirley S. Wang, Wall Street Journal, November 17, 2009