The incidence of BRCA1 and BRCA2 mutations is higher in the Ashkenazi Jewish population and hence studies on population screening have initially been done in Israel. This week we celebrate the Jewish New Year…and the latest JAMA article on population based screening for these mutations was most timely.

The article published in the September 17 JAMA is based on the 2014 Lasker Award. This award in medical science was presented to Dr. Mary-Clair King to recognize and honor her “for bold and imaginative contributions to medical science and society – exemplified by her discovery of a single gene BRCA1 that causes a… form of hereditary breast cancer…” The article both describes the application of this discovery and suggests that population-based screening of women for BRCA1 and BRCA2 should become a routine part of clinical practice.

Just to remind you: BRCA1 mutation carriers have a combined risk of developing either breast or ovarian cancer of 60% by age 60 and 83% by age 80. For BRCA2 mutation carriers, risk is 33% by age 60 and 76% by age 80.

A recent study in Israel recruited more than 8000 healthy Ashkenazi Jewish men. The men were tested as a gateway to families for breast and ovarian cancer. (The men were unaffected by breast-cancer themselves but if they were positive, it would enable researchers to identify female mutation carriers, not based on their personal or family history of cancer.) 175 men were identified as carriers of the mutation and genetic testing was offered to all of their female relatives. Surprisingly, 50% of families found to harbor BRCA1 or BRCA2 mutation had no history of breast or or ovarian cancer that would have triggered clinical attention. However, female mutation carriers from these theoretically low-cancer- incidence families had similar cancer risks to female carriers from families with high cancer incidence. Low-cancer-incidence families were simply smaller with fewer females and hence were less likely to exhibit a significant breast or ovarian cancer history.

The authors of the article point out that without population-wide screening, women with BRCA1 or BRCA2 mutation from such families would not have been identified until they developed cancer; a failure of cancer prevention. This study has significant implications for preventive care in Israel which has a large population of Ashkenazi Jews. But in another study, it was found that only 35% of families with high incidence of breast or ovarian cancer had even previously been referred for genetic counseling, despite common knowledge of the increased risk due to BRCA1 and BRCA2 in the Ashkenazi Jewish population and the availability in that country of free testing and counseling.

In the United States, the number of carriers of mutations in the BRCA1 and BRCA2 genes is estimated to be between 1 in 300 and 500 women or between 250,000 and 450,000 adult women for whom breast and ovarian cancer is both highly likely and potentially preventable. Wide scale population genetic counseling and screening should go on our medical wish list. But at present, the US Preventive Services Task Force (USPSTF) supports BRCA1 and BRCA2 testing based on family history and ancestry, but not for the entire female population. Unfortunately only 19% of US primary care physicians accurately assess family history for BRCA1/BRCA2 testing. This is clearly unacceptable.

The author states at the end of the article that “population wide screening will require significant efforts to educate the public and to develop new counseling strategies, but this investment will both save women’s lives and provide a model for other public health programs in genomic medicine…. Women should have the choice to learn if they carry an actionable mutation in BRCA1 or BRCA2.” We have much to learn and do…

The media has been recently focused on this (at least when not reporting on ISIS). It’s likely that many of you have heard about the report that came out comparing mortality rates for three types of surgery for breast cancer: bilateral mastectomy (both breasts), unilateral mastectomy (single) or lumpectomy with radiation. The article that the media has been quoting was published in the September 3 issue of JAMA.

The reported study included 189,734 California women who were diagnosed with breast cancer in stages 0 to 3 between January 1998 and December 2011. The researchers reviewed the types of treatments they received, their follow up and the death certificates of those who died during the follow up. They excluded those women who were diagnosed after 2010 because of incomplete mortality data. If appropriate records were not available they also eliminated some of the patients, so basically, the final analysis included 174, 917 women whose medium follow up time was 89.9 months. (I am not sure you wanted all these numbers but I thought I would try to be as exact as possible,at least at the beginning of this website article.)

What they found was that the rate of bilateral mastectomy increased from 2% in 1998 to 12.3% in 2011 and this represented an annual increase of 14.3%. Women younger than 40 were most likely to have an increased rate of bilateral mastectomy which went from 3.6% in 1998 to 33% in 2011. This procedure was more often used by non-Hispanic white women, those with private insurance and those who received care at a National Cancer Institute (NCI) designated cancer center (8.6% among NCI cancer center patients versus 6% among non-NCI cancer patients). Unilateral mastectomy (obviously on the side diagnosed with breast cancer) was more often used by racial/ethnic minorities and those with public/Medicaid insurance (up to 52%). Breast conserving surgery with radiation was done in about 55% of all patients but again varied according to age, insurance and tumor size.

The important conclusions of the study was that compared with breast conserving surgery (lumpectomy) with radiation that had an overall ten-year mortality of 16.8%, unilateral mastectomy was associated with a higher all-cause mortality and a ten-year mortality rate of 20.1%. There was no significant mortality difference between lumpectomy and radiation and bilateral mastectomy (in which the ten-year mortality rate was 18.8%).

I know these mortality rates seem high. But there was a huge variability in cancer stage between zero and stage III, so the rates included the higher stage cancers. The study was not randomized and treatment was dependent on a lot of other factors including size of the tumor, tumor features that suggested a poor prognosis as well as lymph node metastases, receptor status and genetic changes which could worsen the prognosis. And as new reconstruction procedures were developed (which look better and allow symmetry), it was likely that some women would choose to have bilateral rather than unilateral mastectomy. Finally, younger women who have a longer period of time for risk of recurrent or new cancer or have a higher probability of carrying genetic mutations were more likely to chose to have surgery on both breasts.

The conclusion of the authors was that although the use of bilateral mastectomy increased throughout California through 2011, overall it was not associated with lower mortality than that achieved with breast conservativeness surgery and radiation. Unilateral mastectomy was actually associated with higher mortality than the other two surgical options.

I want to add my own take on this… it is an important study, but the fact that so many stages of breast cancer were lumped together and prognostic features were varied, there are significant drawbacks. Today with MRI, genetic tumor analysis and profiling, the prognosis of a woman’s breast cancer is more defined, allowing therapy to be targeted and of course improved. When deciding on the course of surgery, considerations of family history, ability to follow up with therapy and surveillance as well as complications of radiation and/or extensive surgery warrant careful consideration. Insurance status is an issue and is unfortunate; hopefully in the future no woman will be denied appropriate care. Every woman who has a diagnosis of breast cancer should carefully consider all choices of therapy with her physicians. Taking a few weeks to consider these will not make a difference in the outcome. This study should be part of the discussion.

There is a precancerous condition that can lead to esophageal cancer called Barrett’s esophagus. When we complain of the heartburn symptoms that can be due to GERD (gastroesophageal reflux disease) most physicians (and those ubiquitous TV ads) suggest an antacid or a PPI (protein pump inhibitor such as Nexium and Prevacid). There is a concern however, that if reflux symptoms continue, long term use of the PPI’s or antacid may cause us to ignore the warning sign that Barrett’s esophagitis or even esophageal cancer has developed. (Note PPI’s have patient instructions that they should be used for just 14 days and if longer use is needed a physician should be consulted.) Over the last few weeks my reflux has returned and indeed I started a PPI… so my interest was piqued when I read the review article in the New England Journal of Medicine on Barrett’s esophagus. Here are some of the highlights:

It is estimated that 5.6% of adults in the United States have Barrett’s esophagus. This is a condition in which the cells lining the esophagus undergo injury or metaplasia due to damage from reflux of gastric acid produced in the stomach. The metaplastic cells are then more likely than normal cells to undergo malignant changes. This can result in development of esophageal adenocarcinoma which is considered a deadly tumor. Unfortunately, the incidence of this cancer has increased seven fold in the US during the past four decades The diagnosis of Barrett’s esophagus requires a biopsy of the abnormal mucosa cells via endoscopy, a procedure done under anesthesia.

There are both risk factors and protective factors for Barrett’s esophagus and esophageal adenoma carcinoma and I thought it would be interesting to list them.

Risk factors include:

  • Older age
  • White race
  • Male sex
  • Chronic heartburn
  • Age under 30 at onset of GERD symptoms
  • Hiatal hernia
  • Obesity with abdominal fat distribution
  • Metabolic syndrome (obesity, hypertension, prediabetes, high triglycerides etc.)
  • Smoking
  • Family history of GERD, Barrett’s esophagus or esophageal adenocarcinoma
  • Obstructive sleep apnea
  • Low birth weight
  • Consumption of red meat or processed meat
  • HPV infection
  • Protective factors:
  • Use of statins
  • H. pylori infection
  • A diet high in fruits and vegetables
  • Breast feeding (for the mother)
  • Tall height

So look at this list and calculate if you are at risk. If you have ongoing GERD symptoms and especially if you also have significant risk factors, you should consider an endoscopy. There are new therapies for Barrett’s in which the abnormal cells are ablated or destroyed. This has been shown to diminish the risk of esophageal cancer. So talk to your doctor or ask for a referral to a gastroenterologist. Barrett’s is not an esophageal friendly disease.

And if my symptoms don’t go away in the near future I may have to do this… Just so you know, I do follow most of the medical advice I give. I had an endoscopy a number of years ago; thank goodness it was clear.

I have devoted several website articles about the importance of HPV vaccination to help prevent cervical cancer in women and genital and anal cancer in men. I now have another reason to promote this vaccine. It comes from news from the Centers for Disease Control and Prevention reported in last week’s JAMA. The journal summarized an article that was published in the Journal of Infectious Diseases on the correlation between HPV infection and oral and or throat cancers. (Note, there’s a medical journal on everything, I don’t get a chance to read most of them and depend on JAMA or the New England Journal of Medicine to bring important articles to my attention.)

A recent analysis showed that 72% of 557 invasive oral pharyngeal squamous cell carcinoma samples tested positive for human papilloma virus (HPV). In nearly 2/3 of the samples, the investigators detected HPV-16 and HPV-18, the strains most often linked with cervical cancer. The HPV vaccines that are currently available actually target HPV-16 and -18 and therefore should be highly effective against this type of cancer.

The current estimates indicate that worldwide there are about 85,000 cases of oropharyngeal cancers that are diagnosed annually and in the United States about 12,000 new diagnosis are made each year. Most are classified as this type of squamous cell carcinoma. Wouldn’t it be amazing if we could immunize all adolescents and young adults and prevent these often fatal cancers! One more reason to make sure that the vaccine is given.

I know most of you may not be reading this email on Friday because it’s the Fourth of July. I’ll try to send it out earlier or you might pick it up after the holiday. So Happy 4th and enjoy the barbecue, parades and fireworks.

I couldn’t let the week go by without reporting on an article in the June 25 issue of JAMA that reports on a study of breast cancer screening using a method called tomosynthesis. The efficacy of tomosynthesis combined with digital mammogram was compared to digital mammogram only for breast cancer screening. A debate about the utility of digital mammogram has once more been brought up by the recent publication of the 25 year follow-up results from the Canadian National Breast Screening Study. It showed that there was no difference in breast cancer-related mortality in screened women versus controls. Many physicians and organizations have however, countered that these results were not valid for current U.S.policy; that the study was based on mammograms that were of poor image quality and that there were significant problems in randomization. Indeed, 14 more recent studies published between 2001 and 2010 have indeed shown a 25 to 50% reduction in breast cancer related mortality for women aged 42 to 74 years who had modern (and presumably better) types of digital mammogram screening. The American Cancer Society, the American Congress of Obstetricians and Gynecologists and other organizations still recommend screening mammography annually for women older than 40 years. The American Cancer Society also recommends annual MRI for women with a 20 to 25% or higher lifetime risk of breast cancer.

The article in JAMA is a retrospective analysis of screening in 13 centers over two time periods. During the initial period more than 281,000 examinations were done with digital mammogram alone. The second period included more than 173,000 examinations during which patients underwent combined digital mammogram and tomosynthesis screening. I know the word “tomosynthesis” sounds very synthetic biology. It is high tech but but not a biological creation. Basically, it is composed of a set of low-dose images produced by x-rays as they moves across the breast. The images are then put together to form a picture by a computer algorithm (of course) that reconstructs the images as slices of the breast. The advantage is in the resolution and clarity of the final image. An area may look suspicious because tissue overlaps from the pressure of a simple mammogram procedure; tomosynthesis is meant to prevent this effect and hence reduce false densities while making a cancer appear more conspicuous.

So does adding tomosynthesis to usual breast screening make a clinical difference? In this study the authors found that the introduction of tomosynthesis was associated with a significant decrease in recall rate (i.e the. need to get additional films, ultrasound, MRI or even biopsy) of 1.6%. There was however, a significant increase in the biopsy rate (1.3%), but perhaps the biopsies were more likely to confirm a cancer. There was an increase in the cancer detection rate of 0.12%. The latter doesn’t sound like much, but it made a difference for the 1.2 women whose cancer was found per 1000 screenings… They might not have had that early diagnosis with standard mammograms. There is however, as always, a drawback in medical innovation and the one here is that tomosynthesis requires twice as much radiation as a regular digital mammogram. And it is too early to know if adding this procedure will impact mortality rates from breast cancer.

In an editorial in the same journal the authors state that “Recent work has suggested that tomosynthesis is likely to outperform mammogram in finding small invasive cancers and lobular cancers, the ones that are most likely to be lethal.”

This and other studies raise some major questions for both physicians and women. Should we seek screening with tomosynthesis over digital mammogram? Should breast cancer screening centers convert to tomosynthesis and abandoned digital mammography? (Which will be costly.) Right now there doesn’t seem to be enough data or financial incentive to do so. But, tomosynthesis may indeed be an advance over digital mammogram for breast cancer screening and one day may become the norm in breast screening. As usual, I’ll end with the off-stated refrain…More studies are needed.

Oy! (Probably not the best word to start my website this week, but I couldn’t come up with a different one.) Right after I wrote about the recommendations for women who were found to have dense breasts during their screening mammogram, I, and everyone in the media, read the article published in last week’s JAMA titled ” A Systemic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions”.

The authors, who are on the faculties of Brigham and Women’s Hospital and Harvard Medical School, reviewed articles that were published between 1960 and 2014. They searched for information on the benefits of mammogram, harms of mammogram and modes of individualized mammography screening decisions including communication of risks and benefits. The article is long and the citations many, but basically, the conclusion is that there was an overall 15 to 20% decrease in the relative risk of breast cancer-specific mortality as a result of mammography screening. Broken down by age groups, mammography screening was associated with a 15% decrease in breast cancer mortality for women in their 40s and 32% for women in their 60s.

So that’s the good news. The bad news is (according to the article) that the risk of a false positive diagnosis was high… For a 40- or 50- year old woman undergoing 10 years of annual mammograms, the risk of false positive results over that period of time was about 61% and for women aged 66 to 74 who had annual mammograms over 10 years, the false-positive rate was 49.7%. (A false positive result raises suspicion for breast cancer and leads to further testing, additional imaging and/or biopsy but does not result in a cancer diagnosis.) The authors also considered the statistics from published trials on overdiagnosis. (I know this term is difficult to understand when we are discussing breast cancer but basically it means that the type of tumor that was detected, such as DCIS, will not eventually lead to invasive or life-threatening disease and/or the patient will die of something else and not from her breast tumor.)

In order to better convey the context of these statistics, the authors discuss lifetime risk of breast cancer as well as risk at any age. For a woman in United States, the average lifetime risk of breast cancer is 12.3%. However, the 10 year risk of invasive breast cancer at age 40 is “only” 1.5%, at age 50, it’s 2.2% and at age 60 it is 3.5%. (These numbers may somewhat decrease the concerns for many of us who worry about our breast health risk in the decade to come.) The high 12.3% number represents a risk over an entire lifetime… well into our late 80s or even early 90s.

So how do we look at risk-benefit when it comes to screening mammogram? If dollar cost is the issue, it accounts for almost $8 billion in annual health care expenditures in United States. But for those women whose lives have been saved or who had to undergo lesser procedures in order to treat their breast cancer, national cost is probably not an issue. Therapies have improved and most women diagnosed with breast cancer do not die from the disease, even if their tumors were detected without mammography. However, as pointed out in an editorial in the same JAMA issue “many women diagnosed with late stage disease who were not screened recently wrongly blame themselves, encouraging others not to make the same “mistake”. Others attribute their survival to screening mammogram received even when this is unlikely to be the case.”I hope this doesn’t sound too cavalier. These were statements in the articles and I, like many women and physicians, feel that any deaths from breast cancer are tragic.

So how do you decide if and how often you should get screened? The authors give a a list of pointers that should be considered by each woman when she considers making her mammogram appointment and by her physicians who suggest she get screened, especially at an early, under 50 age.

* Many cancers will be found, but most women diagnosed with breast cancer will survive regardless of whether the cancer was found by a mammogram.

* Some cancers that are found would have never caused problems.

* Often, women are called back for further testing because of an abnormality that is not cancer.

* Mammography decreases the number of women who will die from breast cancer. This benefit is greater for women who are at higher risk for breast cancer based on older age or other risk factors such as family history.

* The number of women whose lives are saved because of mammography varies by age. For every 10,000 women who get regular mammograms for the next 10 years, the number whose lives will be saved because of the mammograms over each age group is approximately

- 5 of 10,000 women aged 40 to 49 years
- 10 of 10,000 women aged 50 to 59 years
- 42 of 10,000 women age 60 to 69 years

* If your breast cancer risk is higher than average, you may benefit more from a mammogram than someone with average risk.

* About half or more of women who have a mammogram yearly for 10 years will have a false positive mammogram and need additional studies. Up to 20% of these women will need a biopsy.

* In some women the mammogram will find an invasive cancer or noninvasive conditions such as DCIS that would never have caused problems. We cannot tell which these are so they will be treated just like other cancers. There is about a 19% chance that the cancer is overdiagnosed and treatment may be unnecessary.

I know this all sounds complicated and makes decisions about screening more difficult. But in the end it really has to do with your values and your personal philosophies regarding healthcare. Do you prefer to do more to insure that a diagnosis of this malignancy be made or do you think less is more and want minimize the risk of a false positive result that could cause anxiety, procedures and cost? I prefer the former but realize that many women don’t.

Firm is good, dense may not be… I’ve written articles on the current California law that requires imaging centers to send you a letter if, at time of mammogram, it’s noted that your breasts are dense. And as I expected, I’ve received quite a few phone calls with queries as to what sort of follow up “dense” mandates. The official committee opinion from the American College of Obstetricians and Gynecologists on this subject was published in April 2014 in (you guessed it) the Journal of Obstetrics and Gynecology.

Perky, firm and dense (breasts) are not always synonymous. Dense breast tissue is usually found in younger women. When we are (were) young, our breasts lack abundant fat separating the glands. And some of us stay that way breast-wise… Dense glands in breast tissue absorb more radiation during mammography than fat and look radiographically white whereas fatty tissue allows the radiation to pass through and appears more translucent in the image. A small tumor or calcification that could be the hallmark of a very early cancer or DCIS will also appear white on mammogram. White on white does not allow for good differentiation. And to somewhat complicate the matter it turns out that women with dense breasts i.e. glands that are close together with less surrounding fat, have a modestly increased risk of breast cancer in addition to a reduced sensitivity of mammography to detect cancer.

Just so you know how we categorize breast density by mammogram, the percent of the women within each category and what that means, here is a chart:

DENSITY

PERCENT

MAMMOGRAM
SENSITIVITY

RELATIVE RISK CANCER
(compared to average density)

Almost entirely fat:

10 %

88%

-

Scattered densities:

43%

82%

-

Heterogeneously dense

39%

69%

Relative risk 1.2

Extremely dense

8%

62%

Relative risk 1.4

Once the imaging center lets you know that your mammogram demonstrated that your breasts are dense, their letter then states that this increased density limits their ability to diagnose cancer (which also covers their tuches) and they usually go on to suggest that you discuss this with your physician. In turn, we then may recommend that you get additional ultrasound tests and perhaps even an MRI to address your newly induced concerns. Offering these exams also diminishes potential physician neglect and culpability and, of course, also gives reassurance that a diagnosis of early breast cancer is not missed.

I wish I could leave it at that, but the committee opinion does not agree with this line of action. They negate the need for these extra tests stating they are not appropriate in women with dense breasts who do not have additional risk factors. They state that “current published evidence does not demonstrate meaningful outcome benefits (eg, reduction in breast cancer mortality) with supplemental test (eg, ultrasonography and magnetic resonance imaging) to screening mammography or with alternative screening modalities (eg, breast tomosynthesis or thermography).” They go on to say “evidence is lacking to advocate for additional testing until there are clinically validated data that indicates improved screening outcomes.”

But before we all feel frustrated, please note that the committee did bless mammogram, especially digital mammogram as the best diagnostic screening tool that has consistently demonstrated a reduction in breast cancer mortality. The College does not, however, recommend routine use of alternative or adjunctive test to screening mammogram in women with dense breasts who have no symptoms and no additional risk factors.

I still urge you to call your physician if you get that “density” letter. We can then discuss your risk factors such as family history, previous biopsies, excessive alcohol consumption, obesity, even hormone therapy and try to figure out how to best to assess and reassure you.

It’s been 50 years since the 1964 Surgeon General’s report that stated that smoking was harmful to our health. The Smoking and Health Report (what it was formally called) was based on a review of an estimated 7000 documents. It concluded that “cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking outweighs all the factors; and the risk of developing lung cancer increases with the duration of smoking and number of cigarettes smoked per day, and diminishes by discontinuing smoking.” Just so we women don’t feel left out, subsequent studies and reports stated that it was just as harmful and perhaps even more addictive for women, but I digress…

The January 8 issue of JAMA was dedicated to the last 50 years of tobacco control. In an editorial, some fascinating statistics were presented that I would like to share:

Half a century after the release of the 1964 report, tobacco dependency continues to devastate US society. Nearly 42 million smokers still struggle with this addiction. Unfortunately, even though 70% want to quit only 3 to 5% annually can do so on their own. New estimates of annual tobacco related deaths now approaches half a million in the United States and more than 5 million worldwide. Children and adolescents are especially affected by tobacco dependency through secondary smoke an onset of smoking. Other vulnerable populations include the poor, those with mental illness or substance-abuse disorders, lesbian, gay, bisexual and transgender population as well as the homeless and those who are incarcerated. The tobacco industry spends more than $8 billion a year in the United States to advertise and market cigarettes and smokeless tobacco, while also promoting cigars, pipe-tobacco and newer products which include dissolvable tablets and electronic cigarettes.

But before you grasp your head and begin to shake it and moan oy! there are some encouraging statistics. Although there have been 17.6 million smoking attributable deaths in the last 50 years, it’s estimated that 8 million premature deaths have been prevented because of tobacco control measures. It’s estimated that one-third of the gains in life expectancy for men (30%) and 29% of the gains for women during these past 50 years were due to declines in smoking. Moreover six nations, including the United States, have had reductions in smoking prevalence of greater than 50% during the past 25 years.

Another article in JAMA points out the factors that have helped smoking cessation in the U.S. Firstly, documentation of the danger of environmental tobacco smoke which has led to a flurry of clean indoor air legislation. Currently, 26 states and the District of Columbia ban smoking in enclosed public spaces. Secondly, the 1988 Surgeon General’s report documenting tobacco use as an addiction changed public perception of tobacco use from habit to “of free choice” to true drug dependency similar to that of heroin and cocaine.Thirdly, cigarette tax increases, clean indoor air laws and efforts to prevent adolescents from purchasing tobacco or starting to smoke have proved effective. Fourthly, there has been some very public litigation by private individuals, the States and the US Department of Justice against the tobacco industry. Indeed, there was a settlement in 1998 mandating that the tobacco industry pay the States $246 billion over 25 years. (The tobacco companies are bad… to add to their list if immoral and death producing offenses, in 2006 they were found guilty of racketeering.) But let’s get back to “the making a difference” factors… There are current evidence-based smoking cessation treatments – both counseling and FDA approved medications – that can markedly increase cessation rates among smokers trying to quit. And these will now be paid for by the Affordable Care Act

When an article about cancer risk among children born after assisted conception came out in this week’s New England Journal of Medicine, I definitely paid attention. So many of my patients have used IVF and indeed so have members of my family. Since the introduction of in vitro fertilization in 1978, 5 million children have been born world-wide withy his type of assisted conception. Research has shown that there can be some prenatal complications in children born through IVF, including low birth weight, prematurity and and rare forms of congenital malformations. There has been a concern that IVF can also increase risk of cancer because of a phenomenon called in printing disorders. (This becomes somewhat complicated but just remember that genes and chromosomes might potentially be impacted when they are manipulated and have to come together in an artificial environment.)

The recent article is based on research done in the United Kingdom. Basically the study linked data on all children born through IVF between 1992 and 2008 and data from the United Kingdom National Registry of Childhood Tumors in order to determine the number of children children in whom cancer developed before the age of 15. There were 106,013 children born after IVF. Altogether, they only found 108 cancers. The expected number based on all other non IVF children would have been 109.7. The cancers they looked at where leukemia, cancer of the nervous system, retinoblastoma (a rare cancer of the eye), kidney cancer and liver and muscle cancer.

Before I continue with the long words used to define the types of cancer they accounted for, let me reassure you (and myself) that they found no increase in the overall risk of cancer among British children born after IVF during that 17 year study period. They did find a very slight increase risk of cancer of the liver and muscle but felt that the absolute risk were small. In their discussion the authors stated that “this is reassuring for couples considering assisted conception, children conceived in this way and their families and clinicians”. Yes indeed. As we continue to enter the brave new world of treatment of infertility this is one less thing we should be concerned about.

Now that I have reviewed this article, I don’t want end this week’s website website without adding the following: We have all heard the reports and seen the pictures of the devastation caused by the typhoon in the Philippines. Currently, we know that 10 million people were affected including 3.9 million children. At last count, as many as 1 million people have been displaced and over 23,000 houses were damaged or destroyed. Save the Children’s team is in the Philippines and working on the ground in the hardest hit areas. The organization has doctors and logistic experts there and they have pulled supplies from their warehouses on three different continents and are sending planes filled with blankets, medical equipment, newborn kits, buckets, tents and more to the Philippines. They arrived Thursday in Cebu and the staff immediately began distributing supplies. As we sit safely in our homes, offices or wherever it is we access the Internet (and hopefully this website), we should remember how lucky we are. If you would like to know more and hopefully donate, you can find information about Save’s response (yes, I’m on the board) at www.savethechildren.org. Thank you!

Philippine Typhoon Haiyan Response: every small donation counts: Give online: www.savechildren.org

Many of my patients have noticed that when they come for their exam my nurse asks if they have ever smoked and then enters their response into our electronic medical record. It’s not just that we want to be compliant with the government request for EMR attestation, we also want to know if specific screening should be considered. A recent article in JAMA reviewed a new recommendation statement issued by the US Preventative Services Task Force (if you want to know their acronym it’s USPSTF). In the future, this recommendation will be used by doctors who refer patients for screening and hopefully insurance companies who pay for preventive services. The USPSTF recommends that CT scans be used to target lung cancer in men and women without signs or symptoms of long cancer who are between the ages of 55 and 80 years and who have had a 30 pack year or longer history of smoking or have quit smoking within the last 15 years. A 30 pack year history means that either the person has smoked one pack a day for 30 years or, and here is where mathematics come into play, three packs a day for 10 years (I’m not sure how one could possibly smoke three packs a day but according to some of my patients it was possible, especially in the 60′s!)

There are about 160,000 deaths a year from lung cancer and the estimate is that this strategy would lead to a 14 to 16% reduction in mortality. The significance of this recommendation is that under the Affordable Care Act, private insurers and Medicare will begin reimbursing for the service. According to the article as many as 9 million to 10 million people could be eligible for screening. (Wow!) They also discussed the fact that over diagnosis and over treatment are concerns since in some cases indolent cancers that would not prove fatal would be diagnosed and treated. (This becomes a philosophical question, would we rather over diagnose and get the right ones out? …Also there is currently no way of knowing ahead of time which tumor will be fatal.) And not everyone who is a candidate for screening will want it.

In the end, we all agreed that a lung cancer screening program, no matter how accurate or how well done is never a substitute for smoking cessation and prevention. A 16% decrease in mortality is great, but we would prefer much higher numbers. As we all know it’s better not to start and certainly, the sooner this source of mass mortality is stopped the better… In the meantime, in our world in which people smoked (and unfortunately are still smoking and supporting the tobacco industry), the appropriate individuals should consider getting scanned.

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