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November 19th, 2009

Breast Cancer Screening

The US Task Force on Protective Services has just come out with new recommendations (published in The Annals of Internal Medicine) about breast cancer screening, and those guidelines have raised a huge storm of protest down south.

According to these new proposed guidelines (which many, much more politicized organizations have disavowed, by the way):
        average and low-risk women between the ages of 40 and 50, who up to now had been advised to get annual mammogram screening, are now advised that they don’t need mammogram screening at all;
        women between 50 and 74 are advised to get mammogram screening only every 2 years as opposed to every year previously;
        women over 74 have been told that there is just not enough evidence to tell them what to do, and all women are advised that regular breast examinations are not needed since there is little evidence, according to this expert panel, that regular breast examination saves lives.

All of which is why some American experts and consumer advocates are loudly proclaiming that with the reduction in mammogram screening that’s bound to ensue, there will be a huge upsurge in breast cancer deaths under these recommendations.

So how likely is that to happen?

No one really knows, of course, but I think it’s unlikely to lead to a huge upsurge in deaths from breast cancer, and that must be balanced by the pretty sage assumption that these guidelines might improve the lives of millions of women, because there are several problems with mammogram screening, including especially these:

1) Although nearly everyone agrees that mammogram screening saves lives if done on appropriate groups, there is still a very real and lively debate among the experts as to what age that benefit kicks in at, specifically about whether screening mammograms in women between 40 and 50 save enough lives to justify the huge costs involved in screening so many women in that age group (the vast majority of European countries, for example, don’t offer this service to women under 50),

2) Mammograms pick up a huge number of changes that look suspicious to the mammographer but which don’t end up being malignant (“false positives”), but nonetheless, all such findings lead, not surprisingly, to huge anxiety and needless and potentially problematic “further investigation” (biopsies, which can lead to scarring and infection), and

3) Something we’re becoming increasingly aware of, namely that mammograms pick up some “non-aggressive” malignancies that grow so slowly (or even regress) that they would never matter to that patient (that is, the person with that cancer is much more likely to die of an entirely unrelated condition), yet because they’re cancerous, those malignancies are all removed with all the attendant risks that surgery (and often further treatment, too) carries.

These guidelines are applicable only in the US, of course, but women all over the world are thinking about them, and about the guidelines that apply to where they live.

Bottom line: guidelines are only recommendations for a patient and their doctor to think about, but which they don’t have to follow.

As with everything in this business, educate yourself as best you can, and then make the decision that makes the most sense to you, knowing, I’m afraid, that there is no formulaic answer.

November 10th, 2009

Taking ASA Daily: Should You or Shouldn't You?

With the constant media focus on H1N1, an unintended consequence is that lots of other important heath news has been over-looked, information that will actually impact way more people in a much more significant fashion than H1N1 will.

Take for example, a recent study about ASA in the journal, Drugs andTherapeutics Bulletin.

Despite all the contradictory evidence out there about whether for an average-risk person it’s worth taking ASA or not, millions of people are doing exactly that because some experts still tout it loudly (for example, apparently Dr Oz says it’s a good thing to do and hey, if an expert on Oprah promotes it, it must be the right way to go), and besides, ASA is so prevalent, most people figure, then it must be safe, especially in the small amounts that people usually use for heart and stroke prevention.

But according to this study, for anyone who isn’t at high-risk for a heart attack or stroke, ASA’s heart-prevention effect is 1) not that strong, and 2) is pretty much balanced out but ASA’s well-known but oft-ignored dangerous side effect of leading to more bleeding (from the gut, into the brain, elsewhere).

This even applies, say these researchers, to people who have diabetes and high blood pressure, two risk factors that usually lead doctors to advise that patient to use ASA.

Bottom line: everything - even old, over-the-counter drugs, even “natural” products – have potential downsides, and before starting a course of those things, always balance that against the touted benefits.

November 4th, 2009

Even more on H1N1

Interesting H1N! study from California, where they’ve had a pretty severe time of it – both now and when the H1N1 pandemic first hit.

And in this analysis of just under 1100 patients admitted to hospital with H1N1 infections – that is, the most severely ill flu patients – they came up with two very interesting findings.

First, in this analysis, obesity emerged – as it has in several previous studies – as a major risk factor for death with H1N1.

Interestingly, in the past, obesity does not seem to have been a major risk factor for people infected with seasonal flu viruses.

Also, these researchers found that although the elderly are less likely to develop an H1N1 infection in the first place, if the elderly get sick enough to be admitted with H1N1, they do much worse than younger people; that is, the death rate for severely ill elderly people infected with H1N1 is much higher than the death rate for severely ill middle-aged people.

Just another indication that no one is immune to this potentially serious infection, and although, thank God or whomever that the virus has not mutated and most people who get infected recover without any hassles, this is a potentially lethal infection that is highly preventable with immunization, so really, common sense dictates that anyone who can get immunized, should get immunized.