Routine mammograms and the importance of rating preventive services

This week’s news from the U.S. Preventive Services Task Force (USPSTF) on routine breast cancer screening has caused quite the stir. The USPSTF shared their new ratings of preventive services for breast cancer: Mammograms work really well in women in their 60s, pretty well in women in their 50s and not so well in their 40s. If you want to have mammograms in your 40s prepare for more confusing results including additional imaging to clarify and in some cases, a biopsy to be certain. And their recommendations included a couple of small but important points: breast self exam doesn’t lead to early detection of breast cancer nor do breast exams by doctors (remember we are only talking about women who have NO symptoms). The big news: Doctors and patients in their 40s should talk to each other about what to do rather than just do the same thing all the time out of pure routing. What’s wrong with that?

We seem to have developed the view that more prevention is always better, more testing is better than less, and that more information is always helpful. But this week’s news challenges that notion…and that is what it was meant to do. Making decisions is hard, especially when we have a health problem. But it’s also true when there are health issues we may not have yet. Surprise, life isn’t simple.

The focus in the media has been on the USPSTF recommendations without sufficient attention to some important context issues. These include:

1) Breast cancer (and for that matter almost all cancers) is not one disease. They afflict us in multiple forms each with a different natural history. Some breast cancers are very aggressive and respond slowly if at all to our treatment options. Others are slower growing and very responsive treatment.

2) Mammography is a better test in some people and for some cancers than it is for others, especially when screening at an early stage is what we want from it.

3) The USPSTF focuses on recommendations for primary care doctors for patients with no symptoms getting routine care.

And the politicians on both sides should be ashamed of themselves for treating 16 volunteers from the private sector so shabbily. The USPSTF has been around for 25 years (some silver anniversary). It has always approached ratings of preventive services more rigorously than any public or private body. The task force is focused on recommendations for primary care not for specialists---they assume oncologists would not be seeing many completely healthy women who don’t have cancer. Several of them have spent their careers focused on prevention and have been recognized repeatedly for extraordinary performance. The rest are seasoned clinicians and successful researchers who are at the peak of their careers. The one thing you can be certain of is that each of them could make a lot more money spending their time on some other activity than this one.

So their timing wasn’t great. They meet three times a year and topics to address are planned months if not years in advance. The irony is that if they had paid attention to politics and delayed the mammography decision then we would have to be concerned about a political agenda. They are so independent they don’t think they need a political consultant or pollster --- they make their decisions based on science rather than opinion polls.

So let’s all pause and make sure we really want to vilify 16 scientists from the private sector who just provided prevention ratings for breast cancer preventive services based on the best science available. And the most controversial advice they provided was we should no longer use a cookbook approach to a serious problem but instead talk to our doctors about all the details, the pros and cons.

I think they all deserve one word……thanks.

—John Santa, M.D., M.P.H., director, Consumer Reports Health Ratings Center

Drug prices increase as inflation rate declines

You may want to be extra vigilant buying brand-name prescription drugs these days. Prices for some of the most widely prescribed brands shot up an average 9% this year–the highest rate in over a decade–even as the overall inflation rate actually declined by around 1 percent.

This assessment* comes from Stephen W. Scholdelmeyer, a professor of pharmaceutical economics at the University of Minnesota’s PRIME Institute. The analysis includes drugs such as Nexium for heartburn (up 7.2%), Plavix to prevent blood clots (up 8.2%), Singulair for asthma (up 12.5%), Flomax for enlarged prostate (up 19.7%), and Fosamax and Boniva for osteoporosis (up 6.9% and 18.6%, respectively).

The analysis was done for AARP, which has closely monitored wholesale prices for a group of 219 drugs since 2002. "The pharmaceutical industry should be embarrassed when it sees its own price increases put side-by-side with the general inflation rate," said John Rother, AARP executive Vice President. "Even as the cost of most good and services drops, a person taking just one brand name drug now pays $200 more per year than a year ago."

Q&A: Preventing shingles?

A friend recently had a painful outbreak of shingles. How can I avoid that condition? —F.J.S., Franklin, N.C.

If you’re age 60 or older, you can get the shingles vaccine. About one in four adults who’ve had chicken pox will eventually experience shingles, a painful, blistering rash that occurs when the herpes zoster virus—which lies dormant in the body after a case of the pox—is reactivated by weakened immunity from age, disease, or another factor. The vaccine cuts your risk of a first outbreak in half, and reduces discomfort by about two-thirds in the event you do get shingles. (The odds of a second outbreak are much smaller, only about 1 in 20.) Your doctor should be able to provide the shot, which costs about $150 and is partly covered by most forms of insurance.

Partners in crime: Diabetes and obesity

The number of Americans with type 2 diabetes has almost doubled in the past decade, to an estimated 24 million. That includes the one in four who don’t even know they have the disease. And some experts believe it won't be long before that number exceeds 30 million.

Why the explosion? Obesity. Up to a third of us are now clinically obese. And since the vast majority of people with type 2 diabetes are also overweight, it's no wonder those two disorders are often referred to as twin epidemics. Indeed, three out of four respondents to a Consumer Reports survey of 5,012 people with type 2 diabetes said they were overweight. And overweight respondents were more than twice as likely to say that they were unsuccessful at managing their diabetes.

The good news is that efforts to rein in excess weight can help prevent and control the condition. For example, a three-year study published in the New England Journal of Medicine showed that for people at high risk for type 2 diabetes, a 7 percent weight loss through diet and 30 minutes of exercise, five days per week, resulted in a 58 percent drop in the expected incidence of the disease. And our survey found that efforts to control weight, by improving diet and increasing activity, were effective strategies for helping people successfully manage their diabetes. Diabetes educators and dietitians were rated as being more helpful than primary-care physicians and endocrinologists in educating patients about nutrition.

The bottom line: The solution to tackling obesity and diabetes is simple. You can't choose your parents, but there are no barriers to eating right and exercising.

—Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser

FDA cracks down on Web sites illegally selling prescription drugs

It’s buyer beware when it comes to purchasing prescription drugs over the Internet, but the Food and Drug Administration is looking to weed out some of the bad apples. The agency said it sent warning letters to 136 off-shore web sites that are illegally selling drugs to U.S. consumers.

The concern is that drugs sold by these web sites could pose a danger to consumers. "Many U.S. consumers are being misled in the hopes of saving money by purchasing prescription drugs over the Internet from illegal pharmacies," FDA Commissioner Margaret A. Hamburg, M.D., said in a statement. "Unfortunately, these drugs are often counterfeit, contaminated, or unapproved products, or contain an inconsistent amount of the active ingredient."

The agency said it also notified Internet service providers and domain name registrars that the web sites were violating U.S. law. The providers and registrars could terminate the sites or suspend use of the domain names. The FDA did not identify the web sites, but said that they did not represent U.S. or Canadian pharmacies.

Quit smoking today—and start looking better tomorrow

Fewer wrinkles. Better-smelling breath, hair, and clothing. Healthier teeth and gums. More money in your pocket. An improved sense of taste and smell. A reduced risk of heart disease, stroke, chronic obstructive pulmonary diseases, and cancer of the lungs, cervix, pancreas, throat, intestine, kidneys, and bladder. Most important, up to 10 years added to your life span. Despite these convincing reasons to quit smoking, Americans are not getting the message that smoking can not only shorten your life, but also increase the risk of death in those who come into contact with your secondhand smoke—including your children.

According to a recent study by the Centers for Disease Control, the rate of U.S. smokers in 2008 (20.6 percent) has remained virtually unchanged since 2004, when 20.9 adults reported being smokers. And 20.6 percent translates to 46 million U.S. smokers, 443,000 preventable deaths each year, and $96 billion in annual health-care costs. Hardest hit by the tobacco epidemic are vulnerable populations, including people with lower levels of education.

If you smoke cigarettes, choose to quit today as part of the 34th Great American Smokeout. It’s true that quitting is no simple task—and you may have made several honest attempts before. But considering the damage cigarette smoke does to your looks, on top of your health and the health of those around you, it’s worth another try. Consider these practical ways to help you get started:

Lasting legacy of breast cancer

Surgery for breast cancer undoubtedly saves lives—but for some women, it also leaves a legacy of long-term pain. Now doctors are being urged to identify the women most at risk, so they can treat pain quickly after surgery.

A recent study showed that almost one half of all women who had surgery for breast cancer in Denmark over a two-year period still had pain two to three years later. The pain was mostly in their breast area, although it extended to the armpit, arm, and side of the body for some women.

Half of these women classed their pain as moderate or severe, and many had pain every day. So it’s clearly a major issue that needs to be tackled.

Surprisingly, the main factor that predicted whether a woman had pain was how old she was. Under-40s were the most likely to have pain, with 64 in 100 women saying they still had pain on average of 26 months after surgery. By comparison, only 40 in 100 women aged 60 to 69 said they had pain.

Q&A: H1N1 vaccine and Guillain-Barré risks?

Should I get the swine flu (H1N1) vaccine if I’ve had Guillain-Barré syndrome? —J.M., Irvington, N.Y.

That depends in part on your risk of getting swine flu and becoming seriously ill if you do. It’s true that some studies have associated flu vaccines with a slight increase (about one person per million) in the risk of developing Guillain-Barré syndrome (GBS), a neurological disorder. And some evidence suggests that a previous case of GBS increases your risk of getting it again. But the flu itself can also cause GBS as well as such complications as pneumonia and in rare cases, death. If you’re among the priority groups for H1N1 vaccination—including pregnant women, health-care workers, and people ages 25 to 64 with underlying conditions such as diabetes and heart or lung disease—the shot’s benefits probably outweigh its risks.

FDA says RockHard Weekend may be a dangerous getaway

People who purchased RockHard Weekend, which was marketed as a sexual enhancement supplement, may have gotten much more than they bargained for. The Food and Drug Administration announced a nationwide recall of the herbal supplement because it contains an undeclared compound (sulfoaildenafil) that is similar to the erectile dysfunction drug sildenafil (Viagra), which actually makes RockHard Weekend an unapproved drug. This drug ingredient could pose a threat to unsuspecting consumers because it can lead to dangerously low blood pressure.

The Viagra-like compound, which is not listed as an ingredient in RockHard Weekend, might interact with nitrates that are found in some prescription drugs, such as nitroglycerin. This could result in a risky drop in blood pressure.

If you have experienced any side effects from use of the supplement, consult your doctor. You can also help the FDA monitor the situation by reporting your adverse events to the agency.

Q&A: Viagra and eye problems?

I take sildenafil (Viagra), which temporarily gives a blue tint to my vision. Recently I was also diagnosed with macular degeneration. Will taking sildenafil worsen that? —Name and address withheld

Probably not, but few studies have looked into it. Sildenafil affects vision by blocking an enzyme that helps the eyes process color. But the limited studies available, mostly funded by drug manufacturers, show that effect is transient and appears to have no long-term effect on eye function. A few small studies of patients with macular degeneration or glaucoma taking sildenafil have shown the drug doesn’t worsen either condition within up to five hours of taking it. 

The only eye condition that’s been associated with sildenafil use is a rare blockage of blood flow to the optic nerve that causes a sudden, permanent decrease in vision in one eye—though it’s not clear what role the drug plays, if any, in the condition. If you experience such an impairment, contact your eye doctor right away.

Read more on the side effects of sildenafil, find out if women should take Viagra, and see our Treatment Ratings for macular degeneration (subscribers only).

Avoid dangerous combination: Blood thinner Plavix with some heartburn drugs

The Food and Drug Administration warned today that people who take the blood thinner clopidogrel (Plavix) should not take the heartburn drugs omeprazole (Prilosec, Prilosec OTC, and generics) and esomeprazole (Nexium) because two new studies confirm that the combination could have dangerous consequences. The studies show that omeprazole and esomeprazole—both members of a class of stomach acid-reducing drugs called proton pump inhibitors, or PPIs—can lower the effectiveness of Plavix , putting people at risk of heart attacks or strokes.

Plavix is given to people after a heart attack to help reduce the risk of blood clots that can trigger another attack. The drug can be hard on the stomach and cause gastrointestinal bleeding, so people are often prescribed a PPI treatment, which reduces the amount of acid in the stomach and lowers the risk of stomach bleeding. But previous studies suggested this drug combination may actually increase the risk of having another heart attack. The FDA’s warning is based on two new studies from the makers of Plavix that show that both omeprazole and esomeprazole reduce the drug’s effectiveness because they block an enzyme in the body called CYP 2C19.

The agency said it does not have enough information to draw a conclusion about whether any other PPIs can be safely used with Plavix, but studies into this issue are being conducted. However, a different type of acid-reducing drug called cimetidine (Tagamet, Tagamet HB, and generics) also inhibits the CYP 2C19 enzyme and should not be taken with Plavix.

A healthy weight helps women age better, says study

Can you still fit into your high school clothes? I know I’d struggle after two kids and a decade and a half of marriage. But according to a study released last month in the British Medical Journal, our chances of living long and healthy would improve if we could squeeze into those old clothes.

In the study, researchers looked at the body mass indexes of 17,065 women, and found that the more weight the women gained from age 18 until mid-life, the less likely their chances of being healthy in later life. And it didn’t have to be a significant amount of weight—for every kilogram of weight gain (2.2 pounds), the odds of being alive and healthy into their 70s decreased by 5%.

The study also found that, when compared with lean women (BMIs of 18.5-22.9), the women with a BMI of 30 or above had lowered their odds of living healthily into their 70’s by 79%.

That’s a scary thought. And if I want to lose enough weight to even get close to my high school jeans, I have to overcome two very large obstacles—me and my husband.

I try to eat healthy, trying several stay-thin strategies. I’m a big fan of salads, and have never met a vegetable I didn’t like in at least some form (though I’m still struggling on those beets). My personal weakness is all those luscious, scrumptious carbs. I have been known to burn my fingers ripping apart a hot, crusty loaf of bread fresh out of the oven. 

Preventable hospital infections: To Err is Human, to delay is deadly

Ten years ago, the Institute of Medicine (IOM) released To Err is Human, reporting that as many as 98,000 Americans die every year from preventable medical errors. Today, on the report’s 10-year-anniversary, Consumer’s Union Safe Patient Project is hosting a forum in Washington, DC to call attention to the fact that today, we’re no safer that we were 10 years ago and to draw attention to their report To Err is Human – To Delay is Deadly which estimates that preventable medical harm still accounts for over 100,000 deaths each year.

The event will be attended by prominent patient safety leaders to discuss what needs to happen to keep patients safe, including former U.S. Treasury Secretary, Paul O’Neill, who wrote a recent op-ed in the New York Times on medical harm; Arthur Levin, a member of the original IOM committee and Director of Center for Medical Consumers; Dr. Rick Shannon, Chairman of the Department of Medicine of the University of Pennsylvania Health System, whose work has been featured in the Wall Street Journal, ABC and NPR; Merrill Goozner, author of The $800 Million Pill: The Truth Behind the Cost of New Drugs; Charles Ornstein with ProPublica who co-wrote a groundbreaking series detailing serious failures in oversight by the California Board of Registered Nursing; Maggie Mahar, health care fellow at The Century Foundation, writer of HealthBeat Blog and author of Money-Driven Medicine; and leading patient safety advocates.

What your walking speed can tell your doctor

Doctors are trained fortune-tellers of sorts. But instead of divining the future through tea leaves or Tarot cards, they look to our bodies for clues. If our blood pressure is high, they may warn of heart and circulation problems that could be down the road. Ditto for high cholesterol. But doctors can also draw upon subtler signs — even, for example, our walking speed.

As odd as it may sound, studies show that healthy older adults who walk slowly are at higher risk of falls, disabilities, frequent hospital visits, and other health problems. And, according to a new study, slow walkers also have triple the chance of dying from heart disease, although the reasons aren't yet clear.

The study included 3,208 seniors ages 65 to 85 in France. Each person's walking speed was clocked over 6 meters (almost 20 feet). The researchers then checked on the participants every couple of years. All were in reasonably good health at the start of the study, and didn't have any conditions that could have substantially affected how fast they walked, such as Parkinson disease, dementia, or a disabling stroke.

After five years, 209 people had died, including 99 from cancer, 59 from heart disease, and 51 from other causes (such as infections and respiratory failure). The researchers found that the slowest walkers were three times more likely to have died of heart disease than those who walked at a faster clip. However, they didn't find a link between slow walking and other causes of death, including cancer.

Q&A: What causes easy bruising?

I’m a 75-year-old woman who bruises easily. What could cause that? —J.B., Irvington, N.Y.

Several things. Bruises form when tiny blood vessels near the surface break, causing bleeding that discolors skin. Anything that affects those vessels or the blood’s ability to clot can lead to increased bleeding and bruising. The most likely cause is the natural thinning of the skin with age, which leaves the vessels less protected. Other causes include various drugs, notably the steroid prednisone; the blood thinners aspirin, clopidogrel (Plavix), and warfarin (Coumadin); and diseases of the blood cells, bone marrow, immune system, or certain organs. So be sure to talk with your doctor if you’ve started to bruise easily.