Tell Me What You Want

I am asking readers to tell me what you want.  Not in general, but at a health or wellness talk.  A few weeks ago I was asked to speak at a wellness seminar given at a company for its employees about heart health.  The talk was well received, and we had a good discussion after my presentation.

What struck me was how willing people were, in a room full of co-workers, to ask questions about their personal health.  In the office, we have safeguards to protect privacy at check-in, in the waiting room and at check out.  Yet in this conference room, with people they know listening, I was told about cholesterol results and other tests, treatments they were given, etc.  Granted, we were talking about heart disease, which may not seem as socially or professionally awkward as some other topics, but it still surprised me.

It also made me wonder – what did they want?  My professional interpretation and opinion of their situation, or validation that the choices they had made in their own care were “good choices”?

I did my best based on the information people gave me to address their concerns, while encouraging them to speak to their doctors.  Some had questions understanding what they were treating or how to interpret their results.  Others had decided to try a different therapy (often homeopathic) than what their doctor recommended and wanted my approval – so the answer to my initial question is “both”.

I found it to be a little uncomfortable being asked to approve someone’s decisions with limited information, especially if I didn’t “approve.”  However, the talk and Q&A are for the attendees, not me, so I did my best to give a recommendation and encourage discussion between the person and their doctor.

This is a copy of the talk I gave – I want to thank TheVisualMD for the image support in the talk.

My question to you – if you went to a talk like this what would you prefer?  A general Q&A or time at the end to make a mini-appointment to discuss your questions one on one with the speaker?  Tell me what you want!

The path to wellness begins with a proper diagnosis

Breast Cancer Screening – In October We Wear Pink

It’s October and that means post-season baseball, (sorry Yankees), football season is in full swing and it is Breast Cancer Awareness month. Many athletes, celebrities and people affected by breast cancer in some way are sporting pink clothes or accessories and advocating for breast cancer screening. Why has breast cancer gotten such universal recognition in the US?

Breast Cancer Statistics

  • 1 in 8 women will get breast cancer in the US
  • About 300,000 women will be diagnosed this year
  • About 2300 men will be diagnosed as well
  • 40,000 women will die from their cancer this year – a death rate that is decreasing due to early diagnosis and treatment advances
  • Breast cancer is the 2nd most common cancer in women – the first is skin cancer
  • Breast cancer is the 2nd leading cause of cancer death in women – the first is lung cancer
  • 2.8 million women in the US are either living with breast cancer or post treatment
  • having a 1st degree relative with breast cancer doubles breast cancer risk
  • 85% of women diagnosed have no family history
  • 8-10% of breast cancers are linked to a genetic risk such as the BRCA gene
    • BRCA-1 carries a 55-65% risk
    • BRCA-2 carries a 45% risk as well as an increase in ovarian cancer risk

Breast Cancer Screening Guidelines

Given the number of women affected by breast cancer, as well as the high death rates and the fact that early detection and treatment have improved survival, one would think there would be little debate about the value of breast cancer screening. However, there are conflicting guidelines regarding screening – what age to start, when to stop, and how often to test.

The American Cancer Society (ACS) recommends yearly mammograms beginning at age 40 and continuing as long as a woman’s health and activity level make it feasible to continue.

In 2009 the US Preventive Services Task Force (USPSTF), a key driver of guidelines in the US, changed its recommendation from the ACS guideline to mammograms starting at age 50 and repeating them every other year, stopping after age 74, and eliminating self breast exams.

This change caused a lot of confusion and backlash, and later the USPSTF “softened” its recommendation to include a section stating that all women should discuss the risks and benefits of breast cancer screening with their doctors and make a decision based on their individual concerns.

So there are somewhat conflicting guidelines, but a decision about breast cancer screening should be based on your preference, your doctor’s assessment of your risks and likely your insurance company’s willingness to pay.  As of now, there have not been any major changes to the reimbursement of mammograms.

So how do we screen for breast cancer?

The main screening tool we use is a history!

  • What age did you start menstruating
  • Do you have a family history of breast cancer
  • Have you had breast surgery
  • Have you ever been pregnant

The answer to these questions add context to the next part of screening – a mammogram. A mammogram is an x-ray of the breast taken from 2 angles with the breast pressed against the machine to give a standard view. That image is evaluated for irregularities that suggest cancer.

There are many variables that go into a mammogram – size of the breast, age, and density are several. Density describes the ambient of breast tissue and fat in a breast. Denser breast make it harder to detect abnormalities on a mammogram. Denser breasts tend to be found in younger women, those who never had children, and athletic women. When this occurs, adding an ultrasound of the breasts can improve the reliability of the results.

MRI has been looked at recently as a screening tool – attractive because it does not use radiation, and can create very detailed images. Therefore, it can detect much smaller abnormalities. Currently this is only recommended for very high risk women.

Another technology recently developed is called Digital Tomosynthesis. Similar to a mammogram, the breast is pressed into position but 11 x-rays are taken instead of two. The images are fed into a computer and a 3-D image of the breast is created and evaluated for abnormalities.

MRI and tomosynthesis are not currently recommended for routine screening.

What do I tell my patients?

  • Every patient is unique, and needs their risk factors evaluated
  • Based on the risk assessment, a mammogram and possibly an ultrasound will be ordered
  • I reserve MRI and tomosynthesis to those women with very high risk
  • Breast implants do not change the need for a mammogram – the implants can be maneuvered out of the image so the breast can be assessed

After the study is done, we will decide when to repeat it – usually yearly based on the ACS guidelines.

One important aspect of breast cancer screening that is overlooked is communication – any test, especially one looking for cancer will provoke anxiety, and I try to get results to my patients as soon as possible. In fact, reducing test anxiety was one of the reasons the USPSTF recommended less testing!

Often there will be an area that was not well seen on the mammogram. In this situation, close up views of the area need to be done – called spot compression views. This does not mean you have cancer – it means a closer look is needed.

Regardless of which screening guideline one follows, one thing must be stressed – if you feel something that does not seem normal to you – bring it to your doctor’s attention! Breast tissue does change and often develops cysts (tender lumps) throughout the menstrual cycle, and where you are in your cycle as well as caffeine intake can influence cysts.  These changes tend to go away at the end of a period. When there is a lump – especially if it persists through a complete menstrual cycle – it is not considered screening and all guidelines stress the need to further diagnose a lump – regardless of age. When discussing self breast exams with my patients I tell them to learn what is normal for them – all breast tissue has some irregularities. If something is different from your normal, see your doctor. It may be nothing but all evidence shows early detection improves outcomes – and ignoring a lump will delay things – either peace of mind that everything is ok or the opportunity to find a cancer early.

The path to wellness begins with a proper diagnosis

Colon Cancer – An Ounce of Prevention….

Breaking bad news is one of the hardest parts of my job.  There are times that I have to tell someone they have a new diagnosis – whether diabetes, a sexually transmitted disease or cancer – and it is not easy.  It is even more difficult when I know that some diagnoses can be PREVENTED!  So I am a huge advocate for preventing a disease whenever I can.  March is Colorectal Cancer Awareness month – and this week’s post is an update on how to prevent ever having to hear your doctor utter the horrible words – “You have colon cancer.”

Colon and Rectal cancer will be diagnosed in over 125,000 people in the US this year.  Over 50,000 people will die from it.  Colon cancer is the 3rd most common cancer in the United States.  And the majority of cases are preventable.  So how are colon and rectal cancer prevented?  By screening for them – doing tests that look for cancer – or ideally pre-cancerous lesions, and removing them.  How do we decide when and what tests to do?  By looking at your medical history and your family medical history and determining your risk.

For those at average risk, the current recommendations for colon cancer screening is to begin at age 50.  Why age 50?  At age 50, the likelihood of colon cancer or a colon polyp – a bump in the tissue of the colon that can turn into cancer – becomes high enough that the benefit of doing a test and removing the lesions outweighs the risk of the testing and the procedure.

So what increases your risk of colon or rectal cancer?

  • Colon cancer or precancerous polyps in a first degree relative (parent, sibling)
  • Prior colon polyps yourself
  • A  history of Ulcerative Colitis
  • A family history of a hereditary colon cancer syndrome – familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)

How do we screen for colon cancer?

  • Fecal Occult Blood Testing (FOBT)
  • Colonoscopy
  • Flexible Sigmoidoscopy
  • Barium Enema
  • CT Colonoscopy (also called a Virtual Colonoscopy)

 What are the advantages and disadvantages of each screening method?

  • FOBT  – done yearly; a small amount of stool is placed on a card, and a chemical added to see if there is any blood in the stool.  Best done with 3 consecutive bowel movements at home and returned to the doctor.  This helps detect cancer because polyps or cancer often bleed.  If blood is detected, a colonoscopy is required.
  • Colonoscopy – this a procedure,  done under anesthesia or sedation, where a flexible tube with a camera is inserted in the rectum and passed through the entire colon.  It directly visualizes the colon and any polyps can be removed (preventing them from becoming cancer).  It should be done at least every 10 years (if totally normal) and more frequently depending on risk and findings.  The 10 year interval is based on studies that show it takes about 10 years for a polyp to turn into cancer.  It requires a “prep” – emptying the colon of any stool the day prior to the procedure.  This is the “gold standard” for colon cancer prevention.
  • Flexible Sigmoidoscopy – this is a procedure, where a flexible tube similar to a colonoscopy tube is inserted in the rectum, and the first two feet of the colon are looked at for polyps or cancer.  If they are detected, they can be removed.  It requires a prep to clean the colon.  It can miss any polyps beyond the two feet of colon closest to the rectum.  If any polyps are found, either a colonoscopy or a barium enema to look at the rest of the colon are recommended.
  • Barium Enema – this is an X-ray test where barium is inserted into the rectum and outlines the inside of the colon.  An X-ray is taken to see the outline, allowing polyps that change the outline to be seen.  It requires a prep before the procedure to empty the colon.  If the study is abnormal, a colonoscopy is required.
  • CT Colonoscopy (Virtual Colonoscopy) – a study using a CT scan and computer reconstruction to see the inside of the colon, looking for polyps or cancer.  It takes less time than a traditional colonoscopy.  There is radiation exposure. It does require the same prep as a colonoscopy, and a small tube is inserted in the rectum to pump air into the colon to allow for better imaging.  If the study is abnormal, a colonoscopy is required.

How does this affect my practice?

I recommend a colonoscopy for all my patients over 50 years old.  If there is a family history of colon cancer I recommend starting 10 years before the relative’s age when they had colon cancer or age 50 – whichever is sooner.

Most people dread the prep – cleaning out their colon more than the procedure itself.  Most people sleep through the actual procedure.  The preps have gotten better in that you don’t need to drink as large a volume of liquid as in the past.  It could be considered the most useful cleanse ever!  

I also recommend FOBT yearly between colonoscopies, though current guidelines to not require this.  I make this recommendation because FOBT is easy, and people may delay their colonoscopy or a polyp may develop a little faster than the usual 10 years.

As far as flexible sigmoidoscopy and barium enema, I only recommend them if there is a reason a colonoscopy can not be done.  CT colonoscopy gives a great image of the colon, and if totally normal gives good reassurance that there is no colon cancer.  However, if there is an abnormality, a colonoscopy must be done, requiring a second prep and procedure.

Colon cancer is preventable – and if diagnosed early, curable.  The important thing is to talk to your doctor about your risk and get screened – any method of screening is better than nothing!  I recommend colonoscopy as it allows the best visualization of the colon – and removal of polyps at the same time – one stop shopping.  Telling someone we prevented them from getting cancer is much more fulfilling than telling them they have colon cancer!

The path to wellness begins with a proper diagnosis

Some useful links:

CDC colon cancer screening guidelines

American Cancer Society colon cancer detection guidelines

American Cancer Society colon cancer overview

 

Test me for everything

An Annual Physical is one of my favorite visits. It’s an appointment specifically designated to review your health – both where you are now and where you are heading. It’s the body’s status update. It’s also where I feel I get to know a person a little better, more about your life in general, not just your blood pressure or back pain. Besides having a conversation about your health, a blood test is usually performed. Often, when we get to drawing blood at a physical exam, a patient will say, “Test me for everything.”  Obviously, everything is not possible – so a discussion of what “everything” entails is needed. 

Often, patients use “everything” as a signal for testing for sexually transmitted diseases (STDs).  It is important to know that HIV can not be tested for without your request – so do not assume it is being tested – ASK FOR IT!

Other STD tests usually include HIV, syphilis, gonorrhea, chlamydia and Hepatitis B & C.  Herpes can be tested for in the blood as well, but the test only shows whether a person has been exposed to the Herpes virus, it does not give information on contagiousness or disease activity.

HPV is tested for in women during a PAP smear.  It is a test done on cervical cells – it is not a blood or urine test.  There is no test for men for HPV, unless there is a lesion – usually a wart – that can be biopsied.

So what are the usual blood tests done at a physical?

It depends on your age and gender. The blood tests I order fairly universally:

  • blood count (CBC)
  • sugar (glucose)
  • liver function (AST, ALT)
  • kidney function (BUN, Cr)
  • lipid panel (cholesterol)
  • thyroid function (TSH, Free T4)
  • urinalysis

Often tested, but not “mandatory”

  • iron levels
  • vitamin B12
  • vitamin D

Other tests determined by age, gender or a medical condition

  • high sensitivity C-reactive protein (cardiovascular risk)
  • hemoglobin A1c (for further assessment of diabetes)
  • urine protein (for people with diabetes or hypertension)
  • prostate specific antigen (PSA) – this is ordered after a discussion about risk and benefits
  • other tests can be considered depending on individual risk – advanced lipid testing, imaging studies, stress tests – these depend on your specific medical needs and are not “one size fits all”

Do I have cancer?

One of the most common questions asked when we draw blood is can you tell if I have cancer? Blood tests for cancer or genetic information are not routinely done, with the exception of the PSA in men for prostate cancer.  While there are tests that exist for following some cancers, they have not improved diagnosis – especially the CA-125 test that is touted in many email chain letters for finding ovarian cancer – it is not a diagnostic test but rather a test for following someone with ovarian cancer. Using tests improperly leads to confusion, anxiety, more testing and misdiagnosis!

More cancers can be detected or screened for with specific tests other than blood tests. Colon cancer, breast cancer, cervical cancer and lung cancer all have screening tests (procedures) that improve detection. There are many guidelines as to when these tests should be done – the bottom line is that each person should discuss their individual risks with their doctor to determine what tests should be done, as well as when and how often!

This leads to the biggest issue of testing – interpreting the information in a meaningful way for you.  The FDA recently forced a home genetic testing company, 23 and Me, to stop marketing their kits due to quality and interpretation issues. As more tests are developed, our need to synthesize this information to make good decisions is becoming more apparent.

So, “everything” means different things to different people – so be specific if there is something you wish to have tested.  You can’t assume it is part of everything.  An Annual Physical gives you a snapshot of where you are, and serves as a guide for how to get to where you want to be. Have a conversation with your doctor about your health fears – an annual physical is the time to chart your path to health!

The path to wellness begins with a proper diagnosis