The Big C is now the title of a show, but the term is one that has always been the source of great fear. Many of my patients come in to the office asking to be screened for ovarian cancer. If you have a family history of ovarian cancer, multiple relatives with breast and/or colon cancer, or you had early breast cancer, especially if you are of Ashkenazi Jewish origin, screening is indeed in order. In these circumstances, I suggest a special genetic blood test for BRCA1 and BRCA2 mutations. (The BRCA stands for breast cancer, but these mutations increase risk of breast and ovarian cancer.) If a BRCA mutation is found, screening may not suffice…the current recommendation is that a woman who has a high genetic risk for ovarian cancer undergo ovarian removal (bilateral oophorectomy) subsequent to completing childbearing or by the age of 40. And because of her high risk for breast cancer she should consider whether to undergo prophylactic mastectomy or follow-up for breast cancer with yearly MRI’s. Of course, most women will have neither a high-risk history nor this type of genetic mutation…they are considered “average-risk” But the fear of ovarian cancer remains meaningful for all of us. It is the fifth leading cause of cancer deaths in women…partly because it is usually diagnosed at an advanced stage.

The symptoms of ovarian cancer are very nonspecific and common; most of us have experienced some of them. They include bladder irritation with frequency and urgency, bloating and abdominal distention (and most of us feel that way when we try on old jeans), unexplained weight loss, decreased appetite and and/or fatigue. These symptoms usually occur late in the disease. If ovarian cancer is found while just confined to the ovary, 5-year survival is 92%. Unfortunately when it is found at an advanced stage (spread to other organs in the pelvis or metastasized in other areas of the body) the 5-year survival is only 30%. So it makes sense that if we could screen for this cancer and find it before it spread, the prognosis would greatly improve. This hypothesis was tested in the Prostate, Lung, Colorectal and Ovarian (PLOC) Cancer Screening Trial. The results of the evaluation of two screening tools, transvaginal ultrasound and a blood test of serum cancer antigen 125 (CA-125) were reported in the June 2011 issue of JAMA.

The trial followed 78,216 women at average risk for ovarian cancer between the ages of 55 and 74. They were followed at 10 screening centers in the United States from 1993 to 2001. The trial was done with proper randomization. Half of the women were offered screening with a baseline transvaginal ultrasound, which was repeated annually over an additional 3 years as well as a baseline CA-125 blood test followed by an annual blood test for an additional 5 years. The other half of the women were not offered these tests but received “usual” medical care. The women’s physicians received all the test results and then decided how to interpret and manage them. The participants were followed for a maximum of 13 years for cancer diagnosis and death until February 2010. (I know that’s over a year ago, but it takes time to gather and analyze the data.)

Here are the results: Ovarian cancer was diagnosed in 212 women in the intervention group and 176 in the usual care group. There were 118 deaths caused by the ovarian cancer in the intervention group and 100 deaths in the usual care group (The statisticians then translated this to 3.1 deaths per 1000 person-women years in the intervention group and a slightly lower 2.6 deaths per 1000 person- years in the usual care group.) But get this…. 3285 of the screened women had false positive results (i.e. either the CA-125 was elevated or there was a suspicious mass on their ultrasound). Of these, 1080 of the women underwent surgery to follow-up on the results and 163 experienced at least 1 serious complication (that’s 15% of those who had “unnecessary” surgery). Deaths from other causes (excluding ovarian, colorectal, and lung cancer) were essentially the same in both groups (2924 in the screened women and 2912 in those not screened). There was also no “stage shift”. In other words, screening did not make a difference as to whether the cancer was found at an early or late stage. (I’ll spare you the numbers here….. I know they are becoming cumbersome.)

The conclusion by the researchers and authors was that “annual screening for ovarian cancer as performed in the PLCO trial with simultaneous CA-125 and transvaginal ultrasound does not reduce disease-specific mortality in women of average risk for ovarian cancer but does increase invasive medical procedures and associated harms.”  In other words: There was no advantage to screening, and in some cases it resulted in harm.

There will be additional studies coming out of Europe in which lower thresholds of the CA 125 blood test are used for initial screening (perhaps it will be more sensitive); but there is no doubt that we need a new and better way to detect ovarian cancer at an early stage. Researchers are working on it…I’ll try to keep you posted when you see me and online.

My newsletter just had its birthday! It’s also mine…and as I accept the challenge of getting older and acknowledge the privilege of living longer than most women in the developing world, I’m allowing myself a moment (or at least several paragraphs) of reflection.  Over the past three years, I’ve covered journal articles that I felt would interest my female patients. (I am a gynecologist.) However, over time it’s also become apparent that men (well, at least my husband) glance at my website and so I include non-gender related subjects. Interspersed with these articles, I’ve tried to share some of the personal experiences that have shaped my “raison d’être” as a mother, wife, physician and concerned citizen of the US and the world.

Last year, two of my favorite segments were about my trip to Ethiopia.  I detailed my second trip as a board member of Save the Children to some of our programs in Africa. These programs were developed and “brought to scale” (a public health description that essentially means that once pilot programs succeed they are greatly expanded) to ensure the health, nutrition, education and protection of children, women and their families. I toured newly built classrooms and libraries, and saw the children’s joy at receiving the books and learning materials that they now could access. I visited nutrition programs and health clinics and witnessed the impact of inexpensive medication that allowed women and children to survive HIV/AID’s, pneumonia, malaria and tuberculosis. I listened as a committee of women discussed how to pay back a loan of less than $20 that they had received in order to buy a cow, a sewing machine, build a kiosk, or plant vegetables; the profits of which they would use to send their children to school. I visited reproductive health clinics where girls and women were given health screens, birth control, STD education and prenatal care.

We are so fortunate to live in this country and enjoy the privileges and opportunities given to us. We tend to take  them for granted. (And few of us want to buy a cow.) As we fret about our children and grandchildren’s higher (and higher) education, we don’t worry whether they will know how to write their name or read by the age of 10. Nor (in most States) do we worry that birth control will be unavailable or that childbirth will cause the demise of mother and child.

I don’t like to keep these profound problems and the programs that can address them to myself. In order to generate awareness and participation on the West Coast for this dedicated organization, a small group of women and I have formed the LA Associates of Save the Children.  Our first project is (you guessed it) to build a school. After much deliberation, we decided to build it in Mozambique. Here are some of the reasons we chose this African country:

Mozambique gained independence from Portugal in 1975 after a ten-year struggle and 400 years of colonial rule. The people of the country then suffered through a brutal civil war that lasted 17 years and an entire generation was lost. The country emerged from the war in 1992 with little to offer its hugely growing population of children. There are now 23 million people; 14 million live in rural areas and 55% of the population is under age 18.  Life expectancy at birth is 52; infant mortality is 115 per 1000 births (think 11%) and of the 1000 children who live, 152 will die before the age of 5 (often from preventable causes). Education, the key to the future of the children and the country, is woefully inadequate – especially for girls. Only 46% of children complete any basic education and of those who go to school only 41% can write their names in grades 1-3.

Our LA Associates’ first school will have classrooms, desks, water wells, as well as separate latrines for girls and boys. It will provide books, writing tablets and educational materials. The children will receive the necessary health services they need to be able to stay in school. Save the Children also secures funding from the Mozambique government to provide the monies required to retain the school’s teachers and staff for future generations.

Over the years, I’ve tried to provide many of you with health services and health awareness through my practice, the media, books, and with this website.  I hope you can now give back just a bit (or more). Yes, it’s my birthday and wow, am I fortunate! My fervent hope is to allow more children of the world who have so little to celebrate their birthdays and receive the best gift of all…health, education and a better future. So please help me complete my goal…building this first school within a year’s time.

To read more about building our school and donate online please go to www.savethechildren.org/la-associates. There are some wonderful pictures of the children and village where we will build our first school. Or you can fill out a pledge form (click here) and send a check.

………… And I promise to keep those newsletters coming.

Thank you for your support!  Judith Reichman, MD

As you know when you come for your annual gynecologic visit, the receptionist requests that you update your information, sign a confidentiality form, and she checks on your insurance. The nurse then hands you a small plastic cup and asks you to give a urine sample. So there you are in a cramped bathroom trying to aim the stream into what now seems like an impossibly narrow container and thinking: (a) this is humiliating, (b) why is this necessary, I have no problems with my bladder? and possibly (c) I can’t go, so what am I supposed to do now?

A new article in the Journal Obstetrics and Gynecology aptly titled “In the Trenches” emphasizes the importance of checking your urine.

An immediate urine test can be performed with a “dipstick”, a strip of paper that is specially treated to check for white cells (often present if there is an infection) red blood cells or RBC’s (and the rest of this newsletter will deal with this… if blood is present in the urine, the medical term is hematuria), protein (if elevated, a sign of kidney or even systemic disease), glucose (present in urine if blood levels are high), ketones (elevated with kidney problems or dehydration), bilirubin (elevated in liver disease) and pH (acidity).

The journal article dealt specifically with microscopic hematuria in women. “Microscopic” simply means that there is blood (or red blood cells) in urine but the urine doesn’t look bloody to the naked eye or toilet paper…(I realize this is getting a bit gross!) According to the American Urological Association, “significant microscopic hematuria” means there are three or more red blood cells (RBC’s) per high power field (magnified 40 times) on microscopic examination from two to three properly collected urinalysis specimens. To get a proper sample, the first drops of urine should not be included, just the midstream…all the more difficult to get into that cup. If you have your period, recently exercised vigorously, just had sex or vaginal trauma, obviously blood cells in the urine will not count and the test should be repeated another time.

Once a dip stick test is positive for RBC’s …I (or any doctor) will probably send the urine out for a complete urinalysis. The urine is spun down and the sediment is examined for the number of RBC’s, white cells, and/or bacteria. Often we also do a urine culture to rule out infection. (Most women, however, do know when they have a bladder infection…. they have urinary urgency, frequency and burning.)

So why is it so important to detect microscopic hematuria? Before I relate the possible causes and consequences listed in the journal article, I’ll tell the tale of a patient that I saw a few weeks ago. She was menopausal, had no signs of vaginal bleeding or urinary problems, but a routine urine dipstick test was positive for RBC’s. Her urine was sent out for culture (it was negative) and complete urinalysis. The latter confirmed the presence of a significant amount of RBC’s.. I asked her to repeat the test 2 weeks later and once more it showed RBC’s. I then referred her to a urologic specialist for a complete workup.. This ultimately consisted of cystoscopy and a CT scan of her pelvis and kidneys. She was found to have bladder cancer. It was resectable and curable.. This simple urine test probably saved her life.

The two most frequent causes of microscopic hematuria in non-pregnant women (46% of women do have hematuria during their pregnancy) are cystitis (bladder infection) and kidney stones. Additionally, some women seem to shed RBC’s in their urine without any pathology. But the cause that should be ruled out, especially in women over 40, is cancer. Bladder cancer is the 17th most common cancer in women worldwide. In the United States in 2008 there were 17,770 new cases of bladder cancer diagnosed and 4,270 deaths …that means that there were more deaths annually from bladder cancer in women than from cervical cancer! (A personal aside…. many years ago my paternal grandmother died from bladder cancer.)

The risk factors for urologic cancers in women include age over 40, smoking, a history of exposure to chemicals or dyes, a history of gross hematuria (the “gross” here is a medical term and means that urinary blood is visible), analgesic abuse and a history of pelvic radiation. And here is a fact that seems to appear whenever we discuss most cancers: up to 35% of female bladder cancer cases may be attributable to cigarette smoking!

The recommendations put forth in the article state that a complete work up of microscopic hematuria should include an evaluation of the lower urinary tract (the bladder) and upper urinary tract (the ureters and kidneys) in any “high-risk” patient. Once more, you are at risk if you are over 40, have smoked, have had chemical exposure (hair stylists), have a family history of bladder cancer (I guess that’s me) and/or recurrent urologic disease. The work up should include cystoscopy, x-rays with dye and CT scans.

We all know about the need for Pap smears. It turns out that a urine test is just as important. So please don’t bewail that request to pee in a cup.

I just returned from Israel and frankly would not be able to function without a caffeine push. To add to my thanks for that cappuccino (or 2) is a new study that appeared in the journal Stroke. (Yes, there are journals that are titled for diseases.) Researchers at the very well known Karolinska Institute in Stockholm followed 35,670 women (ages 49 to 83 years) who did not have a history pf cardiovascular disease or cancer over a 10 year period of time. (These women were actually participating in the Swedish Mammography Cohort study looking at links between diet, lifestyle and disease.) They assessed coffee consumption using a self-administered questionnaire. The questionnaire made no distinction between caffeinated and decaffeinated cups of coffee, but it is well known (reference The Girl with the Dragon Tattoo as well as the other novels by Steg Larsson) that decaffeinated consumption of coffee in Sweden is low.

The researchers found that 1 to even more than 5 cups of coffee a day lowered risk for stroke, cerebral infarction (lack of oxygen and death of the tissue from an occlusion of an artery) as well as sub arachnoid hemorrhage by 25%! The amount of coffee did not seem to make a difference; it just had to be a daily beverage. And when they took into consideration smoking, weight, history of diabetes, hypertension and alcohol consumption, the decrease in stoke incidence was still there if coffee was consumed on a regular basis.  Wow! This doesn’t mean that the latter factors are not important…but even if they exist, coffee appears to decrease the risk of those women who are at risk.

The authors of the study suggested that coffee drinking reduces stroke by decreasing mild inflammation, acting as an antioxidant and improving insulin sensitivity. Right now, I just want it to keep me awake!

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