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.

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

Swine flu: Wherefore art thou vaccine?

With the swine (H1N1) vaccine production and distribution slower than expected, many Americans are having trouble finding vaccine, according to a new poll. And the trickle of vaccine has caused problems for mandatory vaccination programs for health care workers, as well as some public health officials when it was reported that Wall Street firms were delivered vaccines while hospitals continue to struggle with a shortage of supply.

Public having difficulty finding vaccine

A poll from the Harvard School of Public Health conducted October 30th through November 1st found that 21 percent of high-priority adults, and 41 percent of all parents tried to get the H1N1 vaccine, but 66 percent of both populations were unsuccessful. In response to the Harvard poll, the Centers for Disease Control and Prevention’s Anne Schuchat, M.D., said, "I’m very mindful of the frustration people have had, whether from information gaps or just the basic availability of the vaccine. I think it should be getting better over the weeks ahead." According to the CDC, the number of vaccine doses available has doubled over the past two weeks, and the supply is expected to continue to grow.

Backlash against Wall Street

The lack of H1N1 vaccine availability also caused a black eye for health officials in New York City, and several Wall Street firms including Citigroup, Morgan Stanley and Goldman Sacks, when it was reported that they were being shipped substantial doses of the vaccine, perhaps ahead of some hospitals. A Wall Street Journal blog summed up reaction to the news:

"It is official: Goldman Sachs is more important than you are…At least that is the way that the public may perceive a WSJ story today that Goldman was one of several Wall Street firms that received large dosages of swine flu vaccines, while some New York City hospitals and clinics are running out of the vaccine."

Video of flu shot cheerleader is misleading

"Dad, have you seen the video of this cheerleader? All of my friends have and they don’t want to get vaccinated if this could happen to them. It seems strange that she can do some things and not other things.  Is this for real?"

That’s the response John Santa, M.D. and Director of the Consumer Reports Health Ratings Center, got from his 23-year old son recently after being reminded to get the two (seasonal and H1N1) flu vaccines.  The concern echoed those expressed by many others after the story was released by FoxNews in mid-October. It reported that a Washington Redskins cheerleader, Desiree Jennings, was diagnosed with a rare neurological disorder called dystonia alleged to be caused by a severe reaction to the seasonal flu shot.  The online story, published October 13th, described that "Desiree now has difficulty speaking, walking, and even eating. During an interview with FOX 5, she had several seizures. The effects are irreversible."

Over the past two weeks Desiree’s story has been picked up by quite a number of other news outlets and blogs and featured on the home page of Generation Rescue, Jenny McCarthy and Jim Carrey's Autism Organization, with the title "Redskin Cheerleader Disabled by Flu Vaccine".

But this is misleading. Dystonia is a rare movement disorder in which prolonged muscle contractions cause twisting and repetitive movements or abnormal posturing. These involuntary movements may affect a single muscle or a group of muscles in the arms, legs, neck or the entire body.  But neurologists all over the country are commenting on professional listservs, saying that Desiree’s video doesn't look like dystonia at all, but rather is likely to be a psychogenic movement disorder, that is, a condition thought to have a psychological origin, and for which there is no physical explanation.

Smart pills: More focus or hocus-pocus?

They’re all the buzz, and more of my patients seem to be asking for them: Drugs that can improve attention span and memory and help them be more productive at work. That may explain why the demand for neuroenhancement medication seems to be gaining steam. Prescriptions for the 18-year-old-and-older age group have been steadily rising, with 3.2 million recorded between November 2006 and October 2007. In one survey conducted in 2008 by the scientific journal Nature, 20 percent of respondents admitted to using neurocognitive-enhancing drugs, mostly to improve concentration.

Examples include stimulants such as Ritalin (methylphenidate) and Adderall (amphetamine/dextroamphetamine combination)—the drugs used for children with attention deficit hyperactivity disorder (ADHD)—to improve performance on academic tests and to learn new skills, and cholinesterase inhibitors like Aricept (donepezil), the Alzheimer’s medication, to treat normal age-related memory changes. They also include Provigil (modafinil), the drug used off-label to keep pilots alert and approved to treat narcolepsy and sleep apnea.

Some say that they’re better than a double-espresso, but do they work? According to new guidance by the American Academy of Neurology (AAN):

ConFLUsion: How to sort out swine flu facts from fiction

It seems that swine flu has infected YouTube. When I was on the Brian Lehrer Show recently, a caller claiming he was a pediatrician announced that the H1N1 (swine flu) virus was "man-made" and another caller urged me to look into this on YouTube because "college students are all over it...". Dangerous rumors like this outlandish conspiracy theory are causing concern all over the country and may be one reason that our swine flu poll found that 43 percent of Americans are on the fence about getting the vaccine. Other ridiculous notions floating around cyberspace include: "there is no swine flu", "a girl got the swine flu vaccine last month and died an hour later", "and you’ll be fine if you don’t eat bacon".

To clear up the misconceptions and give you the facts, we collected a number of rumors we’ve heard on our blog and elsewhere in the media about the swine flu and the swine flu vaccine:

Rumor: It’s better to build up your own natural immunity than gain immunity from a vaccine.

Fact: That was the top reason almost two thirds of those who were unsure or said they would not get their children vaccinated gave for not getting a flu vaccine last year. But that logic misses the whole point of immunity—avoiding disease. When your body is exposed to a virus, it creates antibodies that help fight the disease, When you’re given the vaccine your body makes antibodies that help prevent the disease. In other words, vaccines produce the same antibodies that an infection does, without the inconvenience and misery of having the illness or its life-threatening complications.

Rumor: I’ve never gotten the flu before.

How to catch the flu and how not to—surgical masks may be helpful

Hate it when somebody coughs right into your face and eyes? You're not just germ-phobic, that may be the most likely way to transmit influenza, according to a newly published study.

Researchers from UC-Berkley’s School of Public Health and the University of Illinois at Chicago’s School of Public Health concluded that close contact spraying of respiratory droplets with the influenza virus carried the greatest risk of infection, followed by hand contact with contaminated surfaces, and inhaling particles carrying the virus. The study was published in Risk Analysis: An International Journal published by the nonprofit Society for Risk Analysis, and used mathematical modeling to examine the theoretical risk of catching an influenza A virus—a type of influenza virus that includes the new H1N1 and several seasonal strains—through various types of exposures when a healthy person is caring for someone bed-ridden with the flu.

While these findings are theoretical, meaning they aren’t based on observations of actual people who caught the flu, they do give an idea of the best ways to prevent the flu. That starts with the flu vaccines, which should prevent your body from actually becoming infected. But evidence shows that influenza vaccines aren’t 100 percent effective, so good hand hygiene, covering coughs and sneezes, and avoiding close contact with sick people are crucial—even if you’ve been vaccinated.

Back to School: Dealing with swine flu

Every year, I’ve found myself having to make a quick early morning decision about whether a slight fever, a sniffle or a cough was enough to keep one of my children home from school. But this year, that decision will be impacted by swine flu outbreaks as the nation tries to tamp down an expected increase in disease this fall.

Over the summer swine flu lingered in camps and other places where young people congregate. And because this flu seems to spread most easily among the young, an upswing in infections is expected to coincide with back-to-school season. Those under 5, and people of all ages with other underlying health conditions, such as asthma, diabetes, neuromuscular disorders and heart disease, as well as pregnant women and girls, face an increased risk of complications from the flu.

During the initial outbreak last spring, there was some confusion about school closings, as health authorities and communities at large tried to learn about the disease and implement pandemic flu plans. Over the summer the Centers for Disease Control and Prevention updated its guidance for K-12 schools dealing with flu this year. The new recommendations try to balance the threat of flu, with the social disruption of closing schools. More responsibility for averting outbreaks will be sought from parents, who are being asked to think about those kids at greater risk before dropping off a feverish child at school.

Heavy Metal: When it’s bad for your ears

No, despite the title, this is not another noise blog. Last month I wrote about the health risks of skinny jeans after I saw a magazine ad for a "Skinny jeans challenge" while waiting to see a surgeon for a torn earlobe. Ironically, I, too, had sacrificed my better judgment for the sake of fashion. After years of wearing heavy gold and silver earrings, gravity had caused a split in the piercing that needed to be surgically repaired.

So as I wait for my incision to heal and sit out the three-month period before I can get my ear lobe re-pierced, I did some investigating. Ear piercing has been around for centuries and practiced in many cultures. Over time the custom has grown in the Western world with around 90% of women currently adorning at least one ear with jewelry. Along with this increase in popularity has come a rise in the number of complications, 35% according to one survey of 452 hospital nurses, most of those infections.

It’s not unusual to develop an infection as a result of piercing. Although infections are most often localized to the skin, if left untreated, they can lead to more serious illness including abscess, septicemia (an infection of your blood) and endocarditis (an infection of the heart lining and valves). Earrings may also become embedded in the lobes of children and require surgery. The risk appears to have an association with the practice of using ear piercing guns.

Lasik surgery: Most in our survey were very satisfied

My wife recently expressed frustration that she can no longer see the bedroom clock without putting on her glasses. Knowing the time is important when you wake up in the morning. It can mean the difference between grabbing another hour’s sleep or needing to bounce out of bed and get going. Seeing the alarm clock is apparently a crucial eye test for many folks. In our recent survey of people who had Lasik and other types of laser vision correction, those who were better able to see the alarm clock were among those most satisfied with their results.

Interestingly, although people said they underwent laser vision correction to get rid of their glasses, 55 percent said they still needed to use glasses or contact lenses, at least sometimes, even after the surgery. But this still didn’t interfere with their overall satisfaction: 80 percent of folks were completely or very satisfied and few had regrets. That’s pretty good, especially since in general in health care, we only get things right about 60 percent of the time.

I wear glasses, but only intermittently, and my far vision actually has improved with age. Since I am one of those people who thinks a pair of glasses improves my "mug shot," I never seriously considered Lasik for myself.

Sweet temptation: Getting kids hooked on lollipop flavors

This week I spoke on Good Morning America about the dangers of hookah smoking (also called waterpipe, shisha (sheesha), goza, or hubble bubble) for teens. I blogged about the subject last year after my son—then only fifteen years old—told me how easy it was to get served at hookah bars in New York City. Like many adolescents, he was convinced that, unlike cigarettes, it was not harmful.

In fact, hookahs do use tobacco (referred to as Massel) which comes in a wide variety of flavors— including apple, strawberry, cappuccino, coconut and mango—intended to provide smokers with a pleasant smoking experience. Because it provides a much less irritating smoking experience, hookahs are considered more pleasant by many smokers, and as a result, they may smoke for longer durations and inhale more deeply. A typical one hour session exposes the user to about 100-200 times the volume inhaled from one cigarette and produces far higher blood levels of nicotine because a session involves from 50 to 200 puffs, rather than the 5-10 minutes and 8 to 12 puffs it takes to smoke a cigarette. And studies show that degree of exposure is more than enough to cause nicotine dependence and lead to a cigarette habit.

Tobacco-free kids, a non-profit organization dedicated to reducing tobacco use, reports that tobacco companies have a long history of creating new flavored products that appeal to kids and marketing them aggressively. Internal tobacco company documents released several years ago called this a "graduation strategy" meant to hook kids by starting them with milder tasting, more flavored substances. This trick is also used with a product called "Snus", a non-chew, no-spit oral tobacco that’s available in variety of flavors including peppermint, apple, and cranberry. Also increasingly popular with teens, Snus lets them stay under the radar at school and still get their nicotine fix because it’s stuffed between the lip and the gum.

More on the dangers of skinny jeans

Squeezing into skinny jeans can put you at risk for nerve damage, fertility problems, bladder infections, and even blood clots, according to Consumer Reports' medical adviser Dr. Orly Avitzur.  

On the Today show today, Dr. Avitzur weighed in on this potentially dangerous trend, popular with men and women alike, and spoke on why trying to be more "skinny jeans confident" might not be such a good idea. Take a look (right), and for more on the risks, read the "The dangers of squeezing into skinny jeans."  

—Ginger Skinner

Readers weigh in on lower-back pain

Readers who have lower-back pain have written us a lot since the Consumer Reports Health Ratings Center Survey results were released in April. We’ve heard from chiropractic fans and chiropractic detractors, readers who have problems with opioid medications and readers who use such narcotics without a problem.

Many writers remarked that our coverage had failed to mention treatments that worked well for them. There was a spinal decompression success story as well as a "compression shirt" success story. There were those who were helped by a therapy called the Feldenkrais Method® and those who swore by another called the Alexander Technique. There was a reader who touted the book "Healing Back Pain: The Mind-Body Connection," by John E. Sarno, M.D., and another who touted Esther Gokhale’s "8 Steps to a Pain-Free Back." There was even a reader who advised patience: "Mother Nature's treatment method was just as effective as that provided by the medical professionals, and she didn't charge a fee."

Letters also reminded us that our survey had neglected to ask about a variety of practitioners, including pain psychologists, physiatrists (physicians who specialize in physical medicine and rehabilitation), pain management doctors, muscular therapists, and osteopaths.

To protect your kids’ ears, tone down the volume

Dear Tom and Katie,

Listen up! Your daughter, Suri, is trying to tell you something: The noise is hurting her ears!

Suri, the daughter of famous actors Tom Cruise and Katie Holmes, has been photographed in numerous loud venues: covering her ears with her hands as she was swarmed by paparazzi in Manhattan, exposed to shouting fans at an LA Galaxy soccer match, outside the Broadway performance of The Little Mermaid, and boarding a loud helicopter. At the recent American Idol finale concert, her mother even covered her ears.

It’s not just temporary discomfort that’s a concern. Tom and Katie may be unaware that a large number of children are suffering measurable noise-induced hearing loss (NIHL). According to published research, about 12.5 percent of American children between the age of 6 and 19 have measurable NIHL in one or both ears. Exposure to harmful sounds can injure the delicate hair cells in the inner ear. We have a fixed number of cochlear hair cells and they don’t regenerate, so it’s important to prevent damage in the first place to reduce the need for a hearing aid later in life.

Dr. James F. Battey, Jr., M.D., Ph.D., director of the National Institute on Deafness and other Communication Disorders (NIDCD), explained why prevention is so important:

"Noise-induced hearing loss is cumulative, invisible, and permanent. It’s cumulative because the damage can start when we are young and get worse over time. It’s invisible because it can happen without our even noticing it, particularly in young people, until it’s too late. And it’s permanent because, unlike a broken arm that will heal itself over time if properly set, we can’t ‘heal’ our hearing. Once it’s damaged, it’s damaged for good."

You deserve answers about the risks, benefits of medical care

Patients who come to my office for lower-back pain are often seeking a second opinion because they’ve been told they need surgery. And as it turns out, many get better by waiting it out, which may explain why 35 percent of our Consumer Reports Health Ratings Center survey of more than 14,000 people with lower-back pain said they never consulted a professional at all.

Others improve with a variety of treatments, especially hands-on therapies. Patient preference plays a big role in healing, regardless of the treatment chosen. If a person is not keen on taking medications, the drugs are not likely to be effective (and prescriptions may not even be filled), and likewise, if someone doesn’t want to make the time for regular physical therapy, its benefits are bound to be limited. The decision that will often work best depends on the patient's own beliefs and values. And the choice that is best for one person may not be best for another under exactly the same circumstances.

Enlisting the preferences of patients is part of helping patients reach an informed medical decision. Shared decision making involves a conversation in which patients communicate their values and the relative importance they place on benefits and harms. It also means doctors make sure that patients understand their therapeutic options. This includes explaining the medical uncertainties.