I am writing this on a flight home to LA from New York. I went to the very cold east coast for a Save the Children board meeting and Gala. I participated in three days of nonstop discussions (and celebration) of the humanitarian efforts of this amazing NGO (non governmental organization) for which I have had the honor of serving as a trustee. I did not read any medical journals…so I thought I would share some of the tough challenges that we discussed that threaten children in our current crisis filled world. To do so, I am quoting some of the facts presented to our board at dinner Tuesday night…

2013 was the first time since World War II when more than 50 million people were displaced from their homes as a result of war and violence. Over 15 million refugees fled to developing countries which themselves have significant needs. The drivers of this humanitarian crises are likely to continue and include climate change, population growth with a “youth budge”, urbanization, migration, political instability, religious fundamentalism, intolerance and hate. (The last are my words.) 200 million people have been affected by natural disasters and there are 100 violent conflicts a year. The most vulnerable are children. Child protection, their health, nutrition and education needs are among the most underfunded components of responses by the international community.

Here is where I can proudly report on what Save the Children is doing: During 2014 Save the Children has responded to 90 humanitarian emergencies in 53 countries reaching 8 million people. These include building Ebola treatment centers in West Africa, community education and outreach programs to educate on risk avoidance, diagnosis facilities and programs to care for children orphaned by Ebola. Save the Children’s global outreach concentrates on child protection, health, nutrition and education in countries that few of us will ever visit and may have trouble finding on a map…South Sudan, CAR, Somalia, Sudan, Mali, Ethiopia, Mozambique (I have reported on schools The LA Associates of Save the Children have built in the last two countries), Iraq, Yemen, Syria, Philippines, Pakistan, and India as well as Laos, Myanmar, DRC and Nicaragua (to name a few).

Yes, these are statistics and names of far off countries, and as we read them they may not register on an emotional level. But the story of one child with a name who may die before the age of 5, or may never have a home or family because of conflict and disease, or if that child is a girl and has a greater chance of dying in childbirth than learning to read…when we know that child’s name we begin to care. I have had the opportunity to meet some of these children and their families … I am proud to be a small part of an organization that strives to value their future.

I hope you will decide to learn more by going to savethechildren.org.

Next week, I will resume my usual women’s health update articles.

Smoking is the number one cause of lung cancer and lung cancer is the leading cause of cancer related deaths in the United States. (More than breast, colorectal and prostate cancer combined!) A proper medical history should always include a smoking history and medical care should include therapies (and ongoing encouragement) to stop if a patient is still smoking. But what about screening and follow up? Despite advances in diagnosis, staging and treatment, only 18% of patients with lung cancer are still alive five years after diagnosis.There is an understandable goal by all of us to do better…

An article published in the November 6 issue of the New England Journal of Medicine has provided data that helps improve smoking mortality statistics; it demonstrates the efficacy of screening with low-dose CT scans of the lungs. The National Lung Screening Trial (NLST), enrolled more than 50,000 persons at 33 US centers. They included individuals who were 55 to 74 years of age with a smoking history of at least 30 pack years. (That means that they smoked one pack for 30 years or two packs for 15 years or, and I am not sure how one does this…3 packs for 10 years.) They included both current smokers and former smokers who had quit within the previous 15 years.

The findings were very significant. There was a 20% reduction in lung cancer mortality with low-dose CT scan diagnosis and treatment versus those who were diagnosed with lung cancer by simple chest x-ray. In absolute terms, this translated to approximately three fewer deaths from lung cancer per 1000 high risk persons who underwent low-dose CT scanning.This is as great a benefit as that reported for breast cancer mortality with annual mammography screening among women 50 to 59 years of age.

There were false positives…(The scan can pick up abnormalities that are not cancer). To decrease the false positive results and unnecessary biopsies and/or surgery, participants found to have a nodule were followed with additional CT screening and only when a lesion got bigger or more worrisome was a biopsy performed. In the end, relatively few of the surgeries (24%) were performed in patients who had benign nodules.

What also got my attention was the fact that screening with low-dose CT was much more cost-effective among women then among men. Scanning was also more likely to have a mortality impact in the groups with the highest risk of lung cancer such as those who were still smoking and those who were older.

And now a very recent headline: Medicare just announced that they “will cover annual screenings for lung cancer for older Americans with a long history of heavy smoking”. They “will extend coverage for CT scans to Medicare beneficiaries who smoked at least a pack a day for 30 years or the equivalent, even if they quit as long as 15 years ago”. According to their announcement the scans will be free for recipients and “the coverage would apply to beneficiaries through age 74.”

Bottom line: If you are a former smoker of the equivalent of one pack of cigarettes a day for 30 years or, heaven forbid, you are a current smoker and you’re over the age of 55, talk to your physician about getting a low dose CT scan of your lungs. Based on the recent studies and the fact that Medicare has announced that they will pay, this should be affordable (if you are not yet on Medicare) or free if you are 65 or older. Too bad the cost of future CT scans are not charged to tobacco companies every time they sell a pack of their poison!

We all know what comes with our 50th birthday… The advice by your physician to get colon cancer screening. And then comes the yuck factor; discussion of the ways to do a colon cleanse in order to be able to view the interior aspects of this very long digestive conduit with either a “true” or virtual colonoscopy. (I discuss both in previous websites.) Although I know that the best way to detect precancerous polyps and/or early cancer is with colonoscopy, I am willing to discuss alternatives such as the virtual “look see” and now a new stool test. It is aptly named Cologuard.

Remember, when found early colorectal cancer is highly treatable.The five-year survival for early-stage cancer is greater than 90%. And if a pre-cancerous polyp is found and removed the cancer can be prevented! However, 23 million Americans between 50 and 75 are not getting screened as recommended, and as a result, colorectal cancer remains the second leading cancer killer in the United States.

According to the manufactures of this new test, “it offers people 50 years and older who are at average risk for colorectal cancer an easy to use screening test which they can do in the privacy of their own home.” Normally I don’t use my website to talk about new products but I was impressed by the fact that the FDA has approved Cologuard and that Medicare now pays for it.

This is a test in which a small sample of stool is tested for cancer associated DNA markers as well as the presence of occult hemoglobin (blood). When you have a bowel movement, your stool picks up cells that are shed from the colon lining. If any cells have abnormal DNA or there is a minute amount of blood, the test is meant to detect this. If it’s positive it may indicate the presence of colorectal cancer or advanced adenoma (precancerous polyp). Colorguard was studied in a large clinical trial which included more than 10,000 patients at 90 sites in the US and Canada. The participants in the study completed Cologuard as well as a fecal chemical test for occult blood before having a standard colonoscopy. They wanted to see how well Cologuard detected cancer and pre-cancer compared to a colonoscopy. What they found was that Cologuard found 92% of colon cancers and 42% of pre-cancers. When the Cologuard test was negative it was accurate 87% of the time.

These are pretty good statistics…certainly not perfect. But for those who put off screening, don’t have access to a facility that can perform colonoscopy or can’t afford payment, this test may increase early diagnosis and “rule in” those individuals who absolutely need referrals for colonoscopy and biopsy.

The test requires a special collection kit which has to be ordered by your physician. It can’t be purchased over-the-counter. Once you get it there are directions that are fairly easy to follow as to how to collect (a weird word in this context) the stool sample. The kit has prepaid UPS labels so it can be sent to the laboratory that does the testing. The results will then go to your physician.

Or you can do the colon cleanse and bypass this…it is worth a discussion.

I didn’t have a chance to discuss this in my last website and even though I’m a week late I wanted to belatedly acknowledge the International Day of the Girl which was celebrated on October 11. In honor of that day, the CDC sent an email with information that they hoped would raise awareness about the health issues that impact young girls worldwide. They chose seven topics (none, thank goodness about Ebola) that should be addressed in order to promote the health and safety of girls. I thought I would outline them this week:

Binge Drinking
The CDC noted that “alcohol is the most commonly used and abused drug among youth in the United States.” According to their statistics one in five high school girls binge drink and half of high school girls who drink alcohol report binge drinking. That means that they’re consuming four or more drinks on a single occasion. This increases their risk of behavior problems, injuries, sexually transmitted infections, unintended pregnancy and also impacts their risk of becoming addicted to alcohol and future health problems.

Human Papilloma Virus (HPV)
This type of virus causes most cases of cervical cancer as well as vaginal and anal cancer. It’s now calculated that 14 million people including teens become infected with HPV every year! But here’s the good news… We now have an HPV vaccine that protects against the HPV types that most often cause anal, cervical, vaginal, vulvar and mouth/throat cancers in women. I’ve talked to most of my patients who are mothers, as well as my younger patients, about the importance of getting this vaccine and indeed have written several articles on my website. Here is a reminder: The HPV vaccine is recommended for girls and boys when they are 11 or 12 years old. It can lower HPV infection rate for teen girls by half. Unfortunately, only 57% of girls and 35% the boys have started the HPV vaccine series. We have to do better…

Indoor Tanning
As I hope we all know, this significantly increases skin cancer risk. The risk is highest among those who start tanning at a younger age. Nearly 33% of white high school girls have tanned indoors and some start doing this as early as age 14 or younger. Indoor tanning causes melanoma which is the deadliest type of cancer. It also contributes to premature aging. We do have laws that prevent young teens from using indoor tanning salons in California but I’m not sure that they are well followed. Somehow we have to promote the slogan that untanned skin is beautiful (and will stay beautiful longer). So many of us wish we had known this years ago.

Sexually Transmitted Infections (STI’s)
Teens and young adults between the ages of 15 and 24 account for half of all new STI’s. Clearly this is where choice of partner and condoms come into play or should I say foreplay…

Sexual Violence
The CDC reports that studies indicate that 36% to 62% of reported sexual assaults are committed against girls age 15 and younger around the world. In the United States, 40.4% of female rape victims where first raped before age 18.

Suicide
Among 15 to 24-year-olds, suicide accounts for 11% of all deaths annually!

Teen Pregnancy
In 2012, more than 86,000 teens in The United States ages 15 to 17 gave birth. As the CDC points out, this increases their medical risks and results in huge emotional, social and financial costs to the mother and her children. Becoming a teen mom affects whether the mother finishes high school, goes to college, and the type of job she will get.

I listed these alarming stats because I (and the CDC) think we should be aware of the major issues that impact the teen girls in our lives. Ignoring them will not help us address their problems. Yes, we should be celebrating the day of the young girl, but to do so, we need to make sure she stays safe and healthy.

In a week in which we’re supposed to get ready to ask to be written during Yom Kippur “in the book of life” there’s been a lot of news about death, especially Ebola….All the medical journals are now publishing articles about this devastating disease. As a trustee on the board of Save The Children, I’ve been appraised almost daily about the epidemic in the three countries in West Africa where we already have significant programs. Caroline Miles, our CEO has traveled to Liberia where Save the Children and other NGOs are establishing Ebola diagnostic centers, isolation centers and Ebola treatment centers. The consequences of not becoming involved in attempts to treat, contain and hopefully prevent further spread of this disease will have devastating country-wide and global consequences.

But I’m not going to report on Ebola or other diseases in this week’s website. The media is finally doing a good job (especially the New York Times) and so I looked for some novel, not completely medical news to report. I found it in good old JAMA.

In the past, physicians have tended to be Republican. I assume this was for mostly for monetary reasons. (I would try to avoid political discussions with many of my colleagues because I knew we disagreed, especially about their economic woes, which are perhaps currently more valid.) My good news is that the growing ranks of women in the medical profession are shifting political allegiances toward the left.

Women now account for roughly 1/3 of the US physician workforce and happily that proportion is growing. A new study analyzed donations from physicians to national political campaigns between the 1991-1992 election cycle through the 2011-2013 election cycle. Physician campaign contributions increased during this time. But those made to Republicans declined between the mid-1990s and 2012. It was reported that the majority of male physician contributors still backed Republicans but only 31% of female physician contributors supported that party. My take is that this is due to the lack of the official Republican Party’s support of women’s reproductive rights, immigration reform, and funding for causes so many women, especially those involved in health care, care about.

Finally some news that made me smile…May the Jewish New Year bring improved health, governance and stability to all of us.

I’ve been back from vacation this week and have diligently looked at the articles in most of the usual journals. Initially, I didn’t find one that I wanted to report.(Note one article, in the New England Journal of Medicine, dealt with a mutation in a gene in 154 families in Europe and their risk for breast cancer… but I think it was a bit too esoteric to cover in the website.)

I did download an article that appeared in Contemporary OB/GYN which I get online. Under the heading “expert advice” they reviewed an article published in the Journal Radiology (which I don’t read) and that I thought was interesting. This was a study of 1162 women who had primary breast cancer and were 75 or older. Information in their charts from the time of diagnosis was reviewed and accessed for stage, treatment, outcomes, and whether the disease was detected by the patient, her physician or with mammography. The women’s survival rates were then compared. During the study (between 1990 and 2011) mammography detection of cancer over time increased from 49% to 70% and was most common for early stage 1. Detection by a patient or her physician was more common when the disease was more advanced at stage II or stage III. The investigators found that lumpectomy and radiation were common and mastectomy and chemotherapy less common in women who had mammography-detected disease than those with cancers found by the patient or her physician. Additionally, five-year disease specific survival was better in women with invasive breast cancer detected by mammogram (97% versus 87%). The investigators concluded that women who have mammogram-detected cancer were diagnosed at earlier stages, required less overall treatment and had better survival rates than women with cancer detected by themselves or physicians.

Bottom line: Women older than 75 may still derive benefits from mammography screening. I will keep ordering them…

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.

As we read, hear and see the news of the violent onslaughts in Iraq, the ongoing civil war in Syria and learn about the horrific impact of these events on the women and children in these areas as well as in conflict zones in Africa, most of us are appalled and don’t know how to begin to become personally involved. And to add the bad news about these distant emergencies, we now have headlines about the one that is occurring in our own country, namely the wave of young migrants that are crossing the border of Mexico in an attempt to escape violence and severe economic deprivation. I just returned from a board meeting of the Save the Children trustees that was held in Washington, DC. We were updated on these emergencies and what Save is doing to help. If you would like to see some of our programs and our messages, please download from Save the Children’s website. I also suggest that you watch two amazing YouTube videos. The first is titled “Save the Children Most Shocking Second a Day Video”. The link is HERE and the second is “The Most Important “Sexy” Model Video Ever”, watch HERE. I think they will help you (and anyone you want to send these to) understand what this organization is doing and why we all should care, get involved and yes, if possible donate.

Okay, that’s my on-line solicitation, now on to my usual medical website article… JAMA this week had two short stories that I thought would be of interest. One was based on an article that demonstrated that stroke risk increased after shingles infection: When researchers looked at the time at which strokes occurred in relation to shingles episodes, they found that the rate of stroke with significantly higher during the first six months following a shingles episode compared with before an episode. The risk was approximately 63% higher during the first month, 42% higher during the second and third months, and 23% higher during the fourth through sixth months. I have pointed out in previous articles that the CDC now feels that we should all get our shingles shots by the time we reach 50. Without immunization, one in three adults are destined to have shingles as they age. I am sure you have seen those direct to consumer ads that have someone say how horrible their shingles episode was. Indeed it can result in significant pain which lasts for months or even years. So if you have not had your shingle shot you now have another reason (i.e. stroke) to get it.

The second short article had to do with physical activity and the fact that it can stave off diabetes for women who are at-risk for this disease. (This week, the entire Journal was dedicated to diabetes.) Women who develop gestational diabetes are at increased risk of developing type 2 diabetes later in life. About 35% to 60% of women who had gestational diabetes will develop type 2 diabetes within the subsequent 20 years. Studies have shown that a combination of a healthy diet, weight maintenance and physical activity may protect against diabetes in this at-risk group. A new study published in May suggests that even a small increase in physical activity, about 2.5 hours a week of moderate activity like walking, reduces the risk of developing type 2 diabetes. What fascinated me was the additional data… In this study the number of hours per week that participants spent watching television was associated with an increased risk of diabetes. Women who watched 10 or more hours of television each week had a greater risk of developing diabetes than those who watched less, regardless of weight. Perhaps it was their inactivity, their snacking while watching or their exposure to the ads for on unhealthy foods between the shows; but there was a very real association between television viewing and diabetes risk.

Bottom line: Don’t snack while watching television. DVR the shows you want to see so you don’t have to watch all of those ads for unhealthy foods. Get out and walk 30 minutes a day. This advice is appropriate for both at-risk and normal-risk individuals as well as our kids. And don’t put off that Shingles shot. You can get it without a prescription at most pharmacies.

I spent the last week in Berlin at the International Women’s Forum (IWF) conference in Berlin. It was a thrill to be among 700 women from all over the world who have been elected to their respective leadership forums. The panel discussions centered on innovation in areas of education, finance, the internet, human rights and career women in Germany. The most rewarding aspect of the conference was the opportunity to become acquainted with women in leadership roles from all over the world. At this conference, there were very few women from clinical medicine, however there were a significant number of women who had major positions with pharmaceutical and biotech companies. We were all surprised by the fact that in Germany only 6% of women who have two children continue with full-time careers. There seems to be a significant prejudice against working moms. Hopefully this will change…

Now on to medical news… This week’s JAMA reported on the FDA warning against a common procedure used in removing fibroids. The US Food and Drug Administration (FDA) is discouraging the use of a surgical technique that is often used during minimally invasive surgery to treat uterine fibroids. They feel it poses a risk for inadvertently spreading cancer cells from an undetected cancerous tumor. In the past, when there were large fibroids that were clinically bothersome and of concern because of their size, rapid growth, impact on pregnancy, pain, bleeding or pressure, surgery with removal of the fibroids (myomectomy) or hysterectomy would be performed through a large horizontal or vertical abdominal incision (laparotomy). But with the development of power morcellators which basically “chew off” the fibroids so that fragments can be removed separately through laparoscopy, surgeons could switch from a large incisions too much smaller ones. The first power morcellator was cleared for marketing in 1995 and 24 devices are currently marketed for laparoscopic use. In a safety communication released in April, the FDA states that current data has shown that one in 350 women treated for fibroids with a hysterectomy or myomectomy have been found to have an unsuspected uterine sarcoma (cancer of the wall of the uterus). They stated that “if power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s likelihood of long-term survival. For this reason, and because there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma, the FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for uterine fibroids.” The major medical centers have now issued statements about the importance of counseling patients about the procedure and potential risks of morcellaton. Although this warning has received a lot of attention, in many ways it simply points out that a decision about the type of surgery a patient will need and how it is performed will always warrant a discussion about risks and benefits. The minimal procedure of laparoscopy does allow for early discharge and a much faster healing process than the more invasive laparotomy, but consideration about a rare, albeit real risk of having an unknown cancer inadvertently spread should be considered.

Many of my website articles cover medical tests, services and therapies that can significantly impact and increase women’s health spans and lifespans. And I have deplored in some of these reports the fact that so many women have neither access nor insurance coverage to “do the right thing”. Despite all the brouhaha about Obama Care (correctly termed The Affordable Care Act or ACA), it is here, despite partisan controversy, it will stay and it should make a positive difference in the health of millions of women. A single page overview of what we can now expect from the ACA was published by The Kaiser Family Foundation in the May 14 issue of JAMA. Some of the stats of the” before-and-what-will-be after” ACA are important for women to know:

82% of women did have a general checkup in the past 2 years. But in the past 3 years:

  • Only 44% discussed smoking
  • 31% discussed alcohol or drug use
  • 41% discussed mental health issues such as anxiety and depression (at this point I am getting depressed)
  • 70% discussed diet, exercise and nutrition.

Counseling on sexual health issues among reproductive- age women in the past 3 years was inconsistent:

  • 61% were counseled on contraception or birth control
  • 50% on sexual history/ relationships
  • 34% were counseled about HIV
  • 30% counseled about other STDs
  • 23% Discussed domestic or dating violence

Most women thought STD testing is routine, but it was not:

  • 56% did not receive a test
  • Only 14% of doctors or providers recommended a test

Uninsured women have much lower screening rates than insured women

  • Over 70% of insured women were tested for blood cholesterol, mammogram and Pap test in the past 2 years.
  • Less than 44% of uninsured women had cholesterol testing or mammogram
  • 52% had a Pap test

Cost is a barrier

  • More than 50% of uninsured women put off or postponed preventive medical service or a recommended test because of cost
  • 13% of insured women put off these tests

The good (or great?) news is that the ACA requires plans to cover these preventive services with no cost sharing; this means:

  • Cancer screening
  • Chronic condition screening
  • Healthy behaviors counseling
  • Vaccinations
  • Reproductive and sexual health services
  • Pregnancy – related services

According to the Kaiser Family Foundation Survey 4 in 10 women are unaware of this new preventive coverage! So when you your physicians and we ask you about your exercise, diet, smoking, drinking, drug use, contraception, partner history, mental health issues and go over previous medical tests and conditions…we are not being intrusive, but need this information so that we can appropriately go on to discuss, council and screen your health and behavioral issues. And discussion of these health parameters and tests should be covered by your health insurance.

I know all this may be initially cumbersome for the physician and patient (especially since all this has to be entered on an electronic medical record), but let’s all be patient…the ACA should improve our health care and who knows…maybe our health behaviors!

Links

-->