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.

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.

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. 

Pregnant and getting the runaround: My search for a flu shot

Every time I see advice for pregnant women to get a seasonal flu vaccine, I have to laugh—and then rant and rave to anyone who will listen. We’ve all been reminded how important it is for pregnant women to get vaccinated for the H1N1 (swine) flu and the seasonal flu, but it’s not necessarily easy.

This is the second time I have been pregnant during a flu season it’s also the second time I have faced serious obstacles trying to get vaccinated. First, I tried my obstetrician only to find out that, at least where I live in Westchester County in New York, they don't give out the seasonal flu vaccine.

So I tried my internist next. This year, his office is out of flu vaccine altogether. But during my last pregnancy I showed my internist at the time the CDC alert recommending that pregnant women get vaccinated, and he nevertheless refused to give me the vaccine. Even my pulmonologist wouldn't provide the vaccine, even though I have asthma, which puts me at higher risk of complications and severe disease.

For the first pregnancy, my employer at the time hired a nurse to vaccinate the entire company, and she wouldn't give me the shot. I finally, got one from my boss at the time, who also happened to be an M.D.

Q&A: Can soy products prevent breast cancer?

The evidence is contradictory. Soybeans contain estrogen-like compounds called isoflavones that, in animal studies at least, fuel the growth of cancer cells and reverse the inhibitory effects that drugs such as tamoxifen (Nolvadex and generic) have on that growth. Yet Asian women, who tend to consume lots of soy foods, have a lower incidence of breast cancer than do women in Western countries. On balance, it's probably safe for most women to consume soy products as long as they don't go overboard (no more than about 100 mg of isoflavones a day). But women who already have breast cancer or are at high risk for it should limit their consumption.

Ad for eyelash drug Latisse goes too far

The first time I saw this commercial for the eyelash-growing drug Latisse (bimatoprost) back in June, I almost wasn’t sure it was real. Sure, we’d blogged on Latisse several times since it received approval from the Food and Drug Administration in late 2008, mainly urging consumers to think hard before using it, given the cost and unsavory risks. But I still couldn’t quite believe the level of glam-infused over-the-topness the commercial imparted, making a powerful prescription drug that can cost more than $100 a month sound like just a really, really cool new makeup item (and featuring superstar Brooke Shields, no less). If I didn’t know better (and it wasn’t a Tuesday), I would have thought it was a Saturday Night Live skit, like this hilarious take on extended-cycle birth-control pills.

The Latisse commercial might portray it as the new big thing, but it’s not really new at all; it originated as Lumigan, a glaucoma medication approved in 2001 that, in a stroke of pure luck for its manufacturer, turned out to have the unusual side effect of lengthening, thickening, and darkening users’ eyelashes. Hence, a rebranding as the first FDA approved treatment for sparse or inadequate eyelashes, clinically known as hypotrichosis. A representative for Brooke Shields declined to say how long Brooke has suffered from the disease of eyelash inadequacy. But she did confirm that Brooke started using Latisse in February 2009, “after consulting with a doctor who determined she was an appropriate candidate for treatment with LATISSE,” and that she is still using it. If you’re good at math, you’ll know that adds up to around $800 worth of eyelash improvement and counting.

The fact that the Latisse commercial looks like an ad for makeup rather than a drug is only the beginning of what completely freaks me out about it. Somehow this single commercial and its print companions running in magazines like Allure manages to embody everything that’s wrong about direct-to-consumer drug advertising. Specifically:

Q&A: Is mammography worthwhile if I'm in my 40s?

While annual screening for women over age 50 clearly saves lives, the benefits for younger women are less clear. Young women are much less likely than older ones to develop breast cancer.

And the greater density of their breasts makes it harder to spot tumors. As a result, mammography for them may produce less benefit. And that can make the test's risks-mainly false alarms and the anxiety and biopsies they trigger-more disturbing. On the other hand, breast cancer in younger women tends to be especially aggressive. The more breast-cancer risk factors you have the more sensible testing in your 40s becomes.

But most cancers occur in women with no known risk factors. If you're in that group, the decision boils down to how worried you are about breast cancer and how prepared you are for the possibility of a false-positive result.

Q&A: Can dietary steps help prevent breast cancer?

Cutting back on alcohol, red meat, and fat, especially trans fats, are three possible steps. Even a drink or two a day of beer, hard liquor, or wine might slightly increase the risk for breast cancer, possibly by affecting estrogen levels, and two to five daily drinks raises the risk 1.5 times that of teetotalers. Cutting total fat intake to about 15 percent of total calories might also slightly lower breast-cancer risk, especially among high-risk women, according to a study from the National Cancer Institute.

Reducing trans fat, which comes mainly from partially hydrogenated vegetable oil, might be particularly important. European researchers collected blood samples from nearly 20,000 women, then followed them for up to seven years. Women with a high level of trans fat in their blood had up to twice the risk of those with a low level. To limit your intake, check food labels, especially on processed foods, for the trans-fat content.

Watch out for breast tenderness if you're taking HRT

The history of hormone replacement therapy (HRT) goes back further than you might think. A book called The Estrogen Elixir, by Elizabeth Siegel Watkins, describes early experiments performed at a kitchen table in St. Louis by biochemist Edgar Allen, using pig ovaries from a local meat-packing plant. Allen's work led to the discovery of estrogen in 1929. Many years later, a leading brand of estrogen would become the best-selling prescription drug in the United States.

Things have changed a lot over the past few years, and HRT is now linked to some serious side effects, including a higher risk of breast cancer. While the FDA says that HRT can still be used to treat symptoms of menopause, it recommends using the lowest dose that works, and for the shortest possible time.

Unfortunately, it's not always obvious which women have the highest risk of side effects (although the risks tend to increase as you get older). For women facing unpleasant symptoms such as hot flashes, the decision about whether to use HRT can be difficult.

A new study of more than 16,000 women has shed some more light on the topic. Researchers had wondered whether getting breast tenderness during treatment with HRT might be a warning sign of breast cancer. Their theory proved correct.

For women, foot pain often comes on the heels of poor shoe choices

Listen up, ladies: think carefully about your shoe choices today if you want happy feet in the future. That's the message of a new study, which found that women who wear sensible shoes are much less likely to have pain in their hindfoot when they're older.

The study included 1,900 women and 1,472 men who were age 50 or above. They were asked whether they currently had pain, aching, or stiffness in one or both feet, and if so, whether it affected a specific part of their foot. They were also asked about their current and past footwear across five age groups: 20 to 29 years, 30 to 44 years, 45 to 64 years, 65 to 74 years, and over 75 years. The researchers sorted the footwear into three categories: good (low-risk shoes offering lots of support and stability, such as athletic shoes and sneakers), average (mid-risk shoes, such as hard- or rubber-soled shoes and work boots), and poor (high-risk shoes lacking good support and structure, such as high heels, sandals, and slippers).

Overall, 29 in 100 women and 19 in 100 men reported having foot pain on most days. But while men's current and past footwear didn't seem to affect their chance of having pain, women's did. Women who had a history of wearing good shoes were 67 percent less likely to have pain in their hindfoot than those who wore average shoes. (The hindfoot is the rear of the foot, above the heel.) Why the difference? The researchers point out that good footwear is designed to cushion the foot, often with softer soles infused with foam, gel, or other shock-absorbing material. Since the hindfoot receives the largest shockwave with each step, these shoes could help prevent pain in this area.

Turning into your mother can be good for your health

Not all of the changes are good (I still can’t believe I actually used the "If all your friends jumped off a bridge…" speech on my daughter), but it turns out that on the nutrition front, she may have been ahead of her time. Although it pains me to admit it, my mom was right about some things.

Drink your milk. In my earlier years, milk was about as exciting as, well, milk. By my twenties, I only drank a few glasses per month. Now I find myself pushing it on my daughter with all the fervor of an infomercial salesman. Milk gets an "A" grade because of the strong link shown between calcium and healthy bones. But I also think "D" with milk, or rather the lack of vitamin D in our diets. In a recent study published in the journal Pediatrics, researchers found that seven out of ten U.S. children may be vitamin D deficient. Fast becoming haled as a "miracle" vitamin, D has recently been associated with a reduced risk of hypertension and heart disease, preventing bone ailments and maintaining muscle strength. It also lowers the risk of being overweight or obese, prevents cognitive impairments later in life, gives possible protection from colds and flu, and some evidence even suggests vitamin D may protect against some cancers. And if that weren’t enough, having low levels of vitamin D has been linked with an increased risk of death overall. 

According to the USDA, my teenage daughter should be drinking at least 3 cups of low-fat milk a day (although ice cream is made from milk, I have yet to have bought into her argument that the government wants her to eat three bowls of ice cream a day). And with all these potential health benefits, a glass of moo juice (or fortified soymilk or OJ, if you prefer) positively glows with good health.

Don’t even think about leaving this house until you’ve eaten some breakfast. For years I’ve told myself that coffee was a perfectly good breakfast option (coffee’s made from beans, beans are vegetables—so I was having vegetables for breakfast). Yet now I find myself spouting that dreaded phrase from my childhood: "Breakfast makes you smarter." Turns out moms are right on that as well. Several studies have shown that regularly eating breakfast may improve memory, test grades, and even school attendance. There’s also some evidence that kids who regularly eat breakfast are less likely to be overweight as teenagers.

Soda pop is a treat, not a drink. This past summer, the American Heart Association recommended that Americans reduce the amount of added sugars we all consume. And let’s face it, a significant source for many of us, especially teenagers, comes with those luscious little soda bubbles or in the form of an energy or sports drink. Not only are these beverages loaded with calories, for some people they may be replacing more nutritious options (no dear, just because it’s orange doesn’t make it juice).

You don’t need a big piece of meat to have a good meal. Although done for economical reasons (trying to feed four teenagers on a limited budget), my mother was a master at making a small amount of meat "stretch" by using it more as a flavoring than as a main course. There were many "guess what’s in the casserole" nights. Although derided by many as a sign of being economically impoverished, it turns out that the reduction of meat in our diets is yet another way that my mother was ahead of her time. Associated with heart disease, high blood pressure and cholesterol, and even some forms of cancer, a diet high in red meat has been linked to a higher mortality rate. In an article published this past year in the Archives of Internal Medicine, people who ate the equivalent of a ¼ pound burger or a small steak every day had about a 27% higher risk of dying over a 10-year period. So in Mom’s best tradition, break out the casserole recipes and serve up some stew, but keep the meat to a minimum.

—Erin Gudeux, sensory senior project leader

Q&A: Concerns about laptops and fertility problems?

Is it true that working with a laptop computer on your lap may cause fertility problems? My daughter frequently uses her computer this way. —L.B., Bay City, Ore.

She needn’t worry. The research suggesting any fertility risk from laptops is sparse, and it applies more to men than to women. A small 2004 study found that after cradling a laptop in their laps for an hour, men’s scrotal temperature increased by 4 to 5 degrees Fahrenheit (2 to 3 Celsius). While other studies suggest that’s enough to potentially reduce the testicles’ sperm production, it’s about the same temperature increase that a man would get from simply sitting with his thighs together for an hour, or riding in a car for two hours. A greater, though still remote, danger is that some laptops can get hot enough to cause burns. So test the bottom of the machine with a finger before placing it on exposed skin.

7 ways to fewer wrinkles

Some people are born lucky—but for the rest of us wrinkles are a natural part of aging. And defying nature can mean trying out a number of eye creams, overnight serums, collagen-based injectables, and even some pretty interesting "facial toning" devices. While any one or combination of these products may work for you, our sister publication, ShopSmart, has some simple, do-it-yourself ways to prevent those fine lines from getting deeper:

1. Use a facial moisturizer with an SPF of at least 30 to limit the sun’s damage every day, not just when you’re at the beach.
2. Shield your face with a hat and sunglasses when you’re outdoors, particularly on sunny days.
3. Avoid tanning beds. Those ultraviolet rays can be even more intense than the sun’s and can increase your risk of skin cancer.
4. Don’t smoke. Tobacco ranks second only to sunlight in its dire effects on skin.
5. Try not to rub your eyes. Treat hay fever so you’re less itchy and not tempted to rub.
6. Sleep on your back. Mashing your face into a pillow can cause lines to form over time.
7. Get an annual eye exam. If you can’t see clearly, you’re likely to squint, which can create wrinkles.

—Ginger Skinner

A tale of two lumps: U.K. vs. U.S.

Listening to our president last night, I was reminded of what happened to me as an American living in Brighton, England, several years ago. No, this isn’t a story of medical error and tragedy—it’s just a story of routine health care and two small journeys that give some perspective on what patients go through in England and in the U.S.

I’ve found a lump in my breast twice: In the U.K. four years ago and last year here in the U.S. In both cases, I went to my primary-care doctor and received thorough and compassionate care. But after that, the series of small events highlight the deep flaw I’ve found in the American health-care system.

After finding the lump

U.K.: The nurse practitioner made an appointment for me to go to the special breast unit at my local hospital the next day.

U.S.: I left with a prescription for a mammogram and a list of about 15 imaging centers to call. The next day I made my way through the list, trying to find one that would take my insurance and see me quickly (not as easy as it sounds). In the end I had a choice of three places: one that was nearby but offered a rude receptionist; a second that asked me a barrage of detailed questions I simply couldn’t answer, and left me so frustrated that I burst into tears and hung up; and a third that was far away, but seemed reasonably efficient. I checked all three out on the Internet to find patient reviews. Two hours after making the first call, I put on my thickest skin and made an appointment with the first one to be seen in four days.

The mammogram

U.K.: I showed up at the specialty center and had a mammogram after waiting a half-hour or so. The nurse asked me to hang around while the doctor read the scan. After another hour, the doctor came out and showed me the lump, said they weren’t sure about it and wanted to do a sonogram. After another half-hour, I had a sonogram and needle aspiration.The doctor told me it was a cyst and to be aware that the lump might fill up again.

Don’t put cancer treatment at risk with high dose vitamins

If you have a serious illness, such as cancer, the chances are you’ll want to do anything that might help you beat it. So perhaps it’s not surprising that many women with breast cancer take vitamin supplements, in the belief that they can help with side effects, or even help prevent cancer from coming back.

In fact, a recent survey of women undergoing treatment for breast cancer found that 6 in 10 women were taking antioxidant supplements, and 7 in 10 of those were taking them at high doses.

For many years now, the general assumption has been that antioxidant vitamin supplements (such as vitamin C, vitamin E, beta carotene, and selenium) are good for you. If you’re in good health, the assumption is they’ll help you stay that way. If you’re sick, they’ll help you get better.

But in the last couple of years, these assumptions have been challenged. Antioxidant vitamins don’t seem to offer the protection against conditions like cancer and heart disease that was once hoped. Some antioxidant vitamins (vitamin E, vitamin A, and beta carotene) may even increase the chance of early death.