United States Preventive Task Force – Recommendations for Breast Cancer Screening Creates Confusion

Since I started practicing medicine in 1976 the American Cancer Society, The American College of Radiologists, and the American College of Obstetricians and Gynecologists have all been in agreement on the necessity for breast cancer screening in adult women.  Annual breast exams by a trained examiner were recommended beginning at age 19.  Breast self-exam was taught in most hygiene classes and by educators in physicians’ offices and was felt to be an inexpensive screening test.

It made great sense that early detection saved lives. It made greater sense that individual patients who educated themselves about the normal feeling of their breasts during different phases of the menstrual cycle were more likely to detect an early change and seek medical attention.

Mammograms were recommended for women on an annual or every other year basis beginning at age 40 and then annually from age 50 and above.  There were always individual variations for women who were at high risk or who had a family history of breast cancer at a young age but, for the most part, breast cancer screening suggestions were not controversial or forever changing.

In November 2009 the United States Preventive Task Force, the same group who questioned the efficacy of yearly physical exams and chest X rays annually on cigarette smokers, issued its revised guidelines. They cited the large number of biopsies done of women between forty and fifty for what turned out to be benign fibrocystic breast disease rather than cancer. The biopsies were often the result of an abnormal breast self exam finding a new lump, an abnormal professional exam and or a spot on a mammogram which was equivocal.

Citing the cost and anxiety involved in evaluating a breast abnormality and using research studies as evidence they suggested not teaching or using breast self exam. They additionally recommended changing the initial mammogram back to age 50 unless there was agreement between the patient and physician that their individual needs justified the test.   With women living longer and breast cancer occurring frequently in the elderly, they suggested no longer performing screening mammograms after age 75.

These recommendations have led to great controversy and confusion in the profession and general public. In a recent Harris Interactive Poll 45% of the women questioned felt the USPTF pushed back the recommended age to 50 to reduce health care costs and avoid administering tests. Eleven percent of those polled thought mammograms should begin at age 20 even for women with no risk factors, while 29 percent believe mammograms should start in their 30’s.

What is clear is that confusion reigns. Consultation with your doctor using your family history, personal history of age at the start of menses, pregnancy history, smoking history and medication history will all contribute to the decision when to start breast imaging screening and how often.

I still support breast self exam and an annual exam by a trained practitioner who examines the same patient annually. As physicians and educators, we need to do a far better job of educating ourselves and the public about the reasoning behind recommended changes to health screenings.

New Suggestions for Managing High Blood Pressure in Senior Citizens

The American College of Cardiology and the American Heart Association have issued the first suggestions specifically for the treatment of high blood pressure in patients 65 and older. In the past, most research studies excluded patients 65 or older so it was difficult to extrapolate suggestions for treating younger patients to older patients.  The Hypertension in the Very Elderly (HYVET) trial changed that. It showed that when we lower the blood pressure in patients 80 years and older there is a decrease in deaths from stroke, a decrease in heart failure deaths and, decrease in death from all causes.

The consensus panel made the following suggestions:

1.  The general targeted blood pressure is less than 140/90

2.  Patients with coronary artery disease, diabetes and chronic kidney disease should aim for a BP less than 130/80 mm Hg.

3.  Lifestyle changes should be encouraged to manage milder forms of hypertension. This includes increasing exercise, reducing salt intake, controlling weight, stopping smoking and limiting alcohol to 2 drinks or less per day.  If this doesn’t work then medication treatment is indicated

The group supported the use of the “step care medication choice program” with the introduction of a thiazide diuretic as the first step in blood pressure medication usage.  They then went on to describe the appropriate usage of two medications at once, the use of beta blockers in cardiac patients and the use of calcium channel blockers.

They also supported screening patients’ urine for the presence of protein which would indicate that kidney problems need evaluation.  The group further suggested that the diagnosis of high blood pressure be made based on at least 3 blood pressure readings performed at two or more office visits.

The suggestions were not the more formal evidence based guidelines we have become accustomed to. They were a compromise agreement of a panel of experts from two organizations.  They encouraged further studies of these suggestions in the elderly so that they can accumulate the data they need to make future, firm, evidence-based guidelines.

For the average patient, nothing should change dramatically. As physicians, we will need to identify patients with elevated blood pressure and convince many of the elderly that there are significant benefits to taking medication to control their hypertension. This has been exceptionally difficult in the healthy elderly who develop hypertension in their mid to late 70’s and do not want to deal with the cost or side effect profile of taking “another pill.” Improving their lifestyle will always be the first option to control the elevated blood pressure.  However, the use of medications was strongly supported to control the pressure in those who need additional treatment.

Honey May Be Effective at Killing Bacteria and Thwarting Antibiotic Resistance

I have on many occasions advised my patient’s ill with an upper respiratory infection and a cough to try some tea and honey. The recommendation is based on family suggestions bridging generations plus practical experience in noting its therapeutic effect when I have a cold and cough.  Of course in today’s world of randomized double blinded objective research studies it is nice to have some evidence to back the recommendation up.

Pri-Med released a summary of a study done at the University of Wales Institute Cardiff which shows the benefits of Manuka honey.  The honey is made from the nectar collected by bees from the Manuka tree in New Zealand. This honey apparently can hamper the ability of pathogenic streptococci and pseudomonas from attaching to tissue. This is an essential step in the initiation of acute infections.

Lead author Rose Cooper additionally pointed out that Manuka honey was effective at making Methicillin Resistant Staph Aureus “more susceptible to the antibiotic Oxacillin.” Methicillin resistant staph aureus is resistant to drugs like Methicillin and Oxacillin. They do not improve or cure the infection. If you add honey, the infections are now showing a response to Oxacillin .

This is very clearly early data with more studies needed. It will not prevent me from continuing to extol the virtues of tea and honey, as well as chicken soup, as part of the treatment of a viral or bacterial upper respiratory infection.

There Is A Malaise Among Us

In my professional life, and on this blog, I have complained bitterly about the orthopedic surgery department in my community changing from physicians to technicians to “consultants” as they now prefer to be called.  These same physicians once aggressively sought out hip replacement patients to admit to their surgical service where they would provide admission, discharge oversight and care.  Now, these “consultants” see the patient before surgery, operate and then turn their patients’ post operative care over to their nurse practitioners, physician assistants and technicians as well as hospital based and employed internists or, the patient’s own medical doctor.

The “consultants” will no longer admit the patient to their surgical service, insisting that the patient be placed on the medical service and, they have taken steps to relinquish their skills in post operative and post surgical wound and general care. They see the patient before surgery, in the OR and several weeks later in the office to check on bone and appliance alignment and to remove the surgical sutures.   I am told the impetus for this change in the orthopedic role is cost and liability and based on specialty specific recommendations of consultants.

Over time, I have seen the post surgical stay reduced from 10 days down to less than four days. Patients no longer go directly home from the hospital.  In most cases, they are sent to skilled nursing homes for rehabilitation and strengthening. I have written about how these overregulated and inspected homes are spending so much money on personnel to keep them in compliance that they can’t afford to staff the facilities to provide skill, nursing and care.

With nighttime patient-to-nursing ratios of 40 residents to one nurse; how can anything get done each shift?   I have written about the conveyor belt / revolving door between recently discharged post hospital patients and the hospital Emergency Department using the 911 system and diverting emergency EMTs from true emergent issues to being a transportation corp.

An article in the Journal of the American Medical Association finally added some credence to my observations. Researchers looked at the subject of Medicare age patients receiving primary hip replacements and hip replacement revisions between 1991 and 2008.  They looked at over 1.4 million primary hip replacements and 348,000 hip replacement revisions. When looking at first time hip replacements they found that mean length of stay dropped from 9.1 days in 1991 and 1992 to 3.7 days in 2008.  This resulted in 20% fewer patients going directly home from the hospital and a 17% increase in patients going to skilled or intermediate care nursing facilities by 2007 and 2008.

The good news is that the overall death rate at 30 days declined from 0.7% in 1991 to 0.4% in 2008.  The bad news is that the rate of readmissions rate for complications of the surgery within the first 30 days rose to 8.5% in 2007 and 2008.

When we look at look at hip replacement revisions, the length of stay declined from an average of 12.3 days to 6 days. In hospital mortality declined from 1.8% to 1.2% but 30 day mortality increased from 2% to2.4% and 90 day mortality from 4% to 5.2%.  Fewer patients were discharged to home in 2008 than 1991 with a resulting increase in transfer to skilled and intermediate nursing facilities by about 17% at the end of the study dates.  When hospital readmission rate was looked at for revision of hips the readmission rate increased by 2007 and 2008 significantly

This data is about real human beings. It means we have not figured out the correct length of hospital stay for this procedure. It may mean that we have reduced the expense for the hospital stay while increasing the expense to the system, patients and family in other areas of health care accounting.

With regard to revisions of hips, more people are dying and more people are coming back to the hospital for readmission than in the past.  Maybe the orthopedic surgeons need to spend more post operative time attending to their patients directly for a longer hospital stay before transferring them to the care of others at a nursing home?

The topic is intensely personal to me especially as we approach Mothers’ Day. During the time of the study my Medicare age mother dislocated her hip repair repeatedly. Each time she was brought back to the operating room, given a whiff of anesthesia and the artificial ball joint was forcibly pushed back into the socket. She would awaken, be given a day or so of rehabilitation and oversight by the surgical assistants and mid level providers and then sent back to the skilled nursing facility for strengthening and rehabilitation before returning home. After each episode her orthopedist would tell me how much force and pressure and strength were required to push that hip back into the socket.

On one of those admissions the hospital physical therapist became alarmed by the fact that the involved leg appeared to be two inches shorter and externally rotated on the last day of therapy. She was having difficulty walking and bearing weight.  She called the surgeon who sent one of his staff to see her in her room prior to transfer. That staff member had never met her. He told her that our hospital physical therapy department was “notoriously inaccurate in measuring limbs.”  He didn’t examine the limb or order an x-ray but transferred her to the nursing facility immediately.

Upon arrival she could not stand up and bear weight. The receiving facility physical therapist requested a hip x-ray. The x-ray showed that she had been discharged from the hospital with the hip still dislocated. The ball could not stay in the socket because the pelvic bone had been fractured during one of the attempts to push the ball back in place.

My mom refused to go back to the same hospital or surgical group and was transferred to another center of excellence for extensive reconstructive surgery.  She has never ever walked independently again.

Dutch Diet Drink Reduces Hunger

Obesity is an epidemic negatively impacting our health in America and around the world.  According to the National Center for Health Statistics, over 68% of American adults are overweight or obese.  As we move away from a hard working agrarian society to a society which consumes fast food while getting less activity due, in part, to our technological advances, we are always looking for aids to keep our weight down.

In recent years the pharmacological approach has fallen on hard times due to the many significant side effects associated with diet medications.  Expensive surgery to reduce the stomach size and re-route the intestines has met with mixed success, high costs and adverse effects as well.

Last month, Harry Peters, a research manager of Unilever Research and Development in the Netherlands announced preliminary successful results of a prototype diet beverage. He and his staff concocted a chocolate flavored brew that stayed liquid and palatable when you drank it but firmed up into a thick gel when exposed to the acidic and digestive juices in the stomach.  The gel distended the stomach and produced a sense of satiety and fullness with a resultant decrease in appetite in the vast majority of the study participants. The research is quite preliminary but again presents hope to those of us fighting the battle of the bulge.

“Although the self-reported decreases in hunger are robustly reported in this study, further studies are needed to establish its implications for food intake, compliance to weight loss programs and long-term effects on weight loss or weight maintenance,” Peters and colleagues concluded.