American College of Physicians Breast Cancer Screening Guidance

The American College of Physicians released four guidance statements on detection of breast cancer in women with average risk and no symptoms of breast cancer.

1. Doctors should discuss with their patients the pros and cons of screening with mammography for breast cancer in asymptomatic women with a modest risk of disease between ages 40- 49 years. The potential risks of screening are felt to outweigh the benefits.
2. Clinicians should screen average risk women aged 50-74 years for breast cancer with mammography every other year.
3. Clinicians should discontinue breast cancer screening in women aged 75 years or greater with an average risk of breast cancer and a life expectancy of 10 years or less.
4. Clinical breast examinations SHOULD NOT be used to screen for breast cancer of average risk women of all ages.

These guidance statements DO NOT APPLY to women with a higher risk of breast cancers including those with abnormal screening results in the past, a personal history of breast cancer or a mutation in the BRCA1 or BRCA2 gene.

At the same meeting, data was presented discussing the problems with supplemental whole breast ultrasound in women with dense breasts.  The concern is that all this testing leads to invasive biopsies, over diagnosis and treatment of breast cancer in 1 in 5 patients and complications and increased cost to patients and insurers.  Like most recommendations on breast cancer, and prostate cancer in men, the results and conclusions from following these guidelines will not be apparent until 10 to 15 years from now.

Today’s adult women will either benefit from these suggestions, which have even included no longer teaching adult women how to perform breast self-exam, or they will be the unsuspecting research victims of cost containment. I question the competence of physicians in examining problematic breast disease if they are not being trained how to evaluate a breast and following that with clinical exams. In surgery we usually do not feel a clinician is competent and fully aware of the pitfalls of a procedure until the surgeon has done 200 or more. We additionally know that doing the procedure frequently results in better results than performing a procedure infrequently.

How will that apply if young physicians no longer examine breasts routinely?  How many, and how often, will they need to do an adequate exam to be able to perform when there is a real issue?  Do we actually wish to create a narrow panel of breast experts only at Centers of Excellence who actually know how to examine a breast and use the available imaging modalities safely and effectively?  It seems these ACP recommendations move in that direction.

For several years now I have been a supporter and champion of our community’s Women’s’ Center associated with Boca Raton Regional Hospital. Run by astute future thinking clinicians and researchers, and stocked with state of the art imaging equipment, it provides an option to meet with a counselor, assess your breast cancer risk and enter a screening pathway most individually suited to your personalized needs.  I will continue to support that choice.

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Keep Moving for Cardiovascular Benefits

We keep extolling the benefits and virtues of regular exercise and fitness. Some research studies have documented the intensity and duration of exercise programs with cardiovascular events and mortality. Those who do more and are fitter apparently do much better which surprises few of us.

It comes down to the “which came first the chicken or egg “question?  Are people genetically able to exercise at a high level living longer and healthier because they exercise at a high intensity and duration or vice versa?

It is quite comforting to read the recent study in JAMA by Andrea LaCroix, PhD, MPH and colleagues from the University of California, San Diego that shows the benefits of even modest movement and exercise.  The study was conducted under the umbrella of the Women’s Health Initiative and put pedometers and accelerometers on women to measure activity during waking hours.  Light physical activity was defined as less than 3 metabolic equivalents (Walking one mile in about 22 minutes expends about 3 Metabolic Equivalents of Activity).  They noted that for each hour per day increment in light activity there was a 14% lower risk of Coronary Heart Disease and 8% lower risk of cardiovascular disease.

The researchers evaluated 5,861 women with a mean age of 78.5 years. Average follow-up spanned 3.5 years with study members having 570 cardiovascular disease events and 143 coronary heart disease events. The study group was diverse with there being 48.8% Caucasian women, 33.5 % Black women and 17.6% Hispanic women.

The study’s results and message was clear. Keep moving. Even modest exercise is beneficial in reducing heart attack and stroke risk.

Free Choice of Physicians & Fee for Service Medicine Ending?

The Medicare Payment Advisory Commission is a panel of financial, economic and health policy advisors created by Congress to advise CMS (Center for Medicare Services) and Congress how to pay physicians, health care providers and facilities for services rendered. According to an online article on MedPage they are close to eliminating fee for service payments for health care. CMS has encouraged alternative delivery methods for years. For the most part this has resulted in hospital and health care systems buying up and employing doctors, mid-level providers being substituted for more highly trained doctors and these alternative systems covering care only with their panel of providers and diagnostic and treatment centers.

However, publicized figures have shown these Medicare alternative products actually cost more per patient per year than traditional Medicare. This particular article claimed a 1-2% savings.

We all see the ads for Medicare Advantage plans which, in addition to no co-pay and no deductible, provide for dental care, vision care, eye care and exercise and gym memberships. Apparently 50% of the Medicare population is now enrolled in such a program.

As a 69 year old individual paying into the Medicare system for the last 55 years I see the benefits and cost savings for seniors when they are healthy. What happens however, when you become ill? Clearly the Centers of Excellence for many of the ailments seniors contract are geographically and contractually outside the narrow networks and panels these private insurance companies run and the Accountable Care Organization run plans provide.

If I do not have coverage for the Mayo Clinic or MD Anderson Cancer Center or the Cleveland Clinic or Dana Farber Cancer Center or Johns Hopkins Medical Center then have I wasted 55 years of payments? Do I really want a nurse practitioner in south Florida directing my care off a protocol list of contracted providers or do I want a clinician who sees a dozen cases of this disease per week calling the shots?

I prefer the latter but may not have a choice but to pay out of pocket if MEDPACs recommendations are accepted by CMS and Congress and become law.

Scientific Reports, Media Reports and Ambiguity

Last week I read an article in a peer reviewed journal citing the benefits of a few eggs per week as part of a low carbohydrate dietary intervention for Type II Diabetes.  The information was so meaningful about a controversial food source of protein that I decided to write about it in my blog and pass it along to my patients.  Three days later the American Heart Association and American College of Cardiology discussed the increased risk of cardiovascular events and mortality in individuals consuming three or more eggs regularly. They talked about the detrimental cholesterol being concentrated in the yolk making egg white omelets look healthier than traditional omelets.

In the early 1970’s a VA study was published showing that veterans over 45 years of age who took an aspirin a day had fewer heart attacks and strokes and survived them better than those who don’t.  Fast forward almost 50 years and we have different recommendations for people who have never had an MI or CVA or evidence of cardiovascular disease compared to secondary prevention in individuals who have known coronary artery disease, cerebrovascular disease or diabetes. Throw in the controversial discussions of aspirin preventing colorectal adenomas from developing, aspirin preventing certain types of skin cancers and today’s report that suggests it may prevent liver cancer. Now three studies suggest that in older individuals (70 or greater) the risk of bleeding negates the benefits of cardio and cerebrovascular protection and aspirin may not actually prevent heart attacks and strokes in that age group.

We then turn to statins and prevention of heart attacks and numerous articles about not prescribing them to older Americans.  I saw articles on this topic covered by CNN, the Wall Street Journal, ARP Journal, AAA magazine and in several newsletters published by major national medical centers.  In each piece they caution you to talk to your doctor before stopping that medicine.

I am that seventy year old patient they all talk about.  I have never smoked. I exercise modestly on a regular basis, getting my 10,000 or more steps five or more days a week.  I battle to keep my weight down and find it difficult to give up sweets and bread when so many other of life’s pleasures are no longer available due to age and health related suggestions.

There are clearly no studies that look at patients who took a statin for 15 years and aspirins for over 20 years, stopped them and then were followed for the remainder of their lives.   How will they fare compared to patients who never took them?

I have this discussion every day with my patient’s pointing out the current guidelines and trying to individualize the suggestions to their unique lifestyle and issues. On a personal level, I still have no idea what the correct thing is to do even after discussing it with my doctors.  How can I expect my patients to feel any differently?

Sleep Apnea and Cognitive Impairment

Convincing a patient to undergo a sleep analysis for obstructive sleep apnea is a difficult task. During our history taking session, we ask about excessive snoring, periods of not breathing while asleep, daytime sleepiness and we look at the patient’s body habitus, weight and height. Often, the patient’s spouse or partner has complained about their snoring keeping them up. Most of the time, when I ask about this the response is, “Why go for an evaluation if I am not going to wear that mask anyway?  I have a friend who has a CPAP mask and I am just not going to do that.”

Obstructive sleep apnea and periods of apnea (not breathing) results in the lung blood vessel blood pressure rising.  We call it pulmonary hypertension.  It is different from systemic arterial essential hypertension in that traditional blood pressure medicines do not lower the pulmonary pressures.

If you examine our heart and lung anatomy you realize that the very non-muscular right side of the heart, primarily the right ventricle, pumps blood a short distance to the lungs to exchange gases and removing wasteful gases in exchange for oxygen. That oxygen rich blood returns to the left side of the heart where the very muscular left ventricle pumps it out to the body.

When the body’s systemic blood pressure rises the left side of the heart has to work harder. The muscular left ventricle is much more suited for that task than the right ventricle is suited to pump against pulmonary vessel hypertension.  The result is the right heart fails much sooner than the left side and the treatment options and medications are far less successful.  This explanation to patients is often received, digested and dismissed as hypothetical and down the road.

This week the American Academy of Neurology received a presentation by a group at the Mayo Clinic in Rochester that showed that patients with untreated sleep apnea produced an increased amount of tau protein deposition in the brain. Tau protein deposition is associated with Alzheimer’s disease.  The researchers, led by Diego Z. Carvalho, MD, are not sure if more Tau protein accumulates in brains of people with untreated sleep apnea or if Tau protein accumulation actually leads to sleep apnea?  That research is ongoing.

The lesson is that sleep apnea is something that needs to be diagnosed and treated. I am a fan of referring patients’ to sleep evaluation centers where that is the primary disease state reviewed.

While sleep apnea is one of the abnormalities evaluated, there are many other disorders of sleep that can be recognized and treated to improve patient sleep. At home sleep monitors are available as well but may be limited in diagnosing sleep apnea alone.

If you are determined to have obstructive sleep apnea then treatment choices include weight loss, laser treatment of the uvula, dental appliances to open up your airways, adjustments to your sleep position and many types of facial and nasal CPAP devices.

Most of my patients who try a CPAP mask require 8-12 weeks to adjust to it. Once adjusted to it, their quality of sleep is so good that I rarely have to convince them to keep using it.

Physician Online Reviews

My friend and practice advisor showed me two very negative anonymous reviews of my practice this week. Both were posted within a one-month winter period and were written about family members. They were not written by patients.

My staff and I tried diligently to identify the stated situations as they did not resonate with any of us.  Unfortunately, we were unsuccessful.  That frustrates each of us.

Combined, these reviews were aggressive and unflattering.  They mentioned my age, ego and seemingly lack of compassion.  I’d be lying if I said I wasn’t bothered by them.  I truly wish I could talk to those anonymous authors to learn their point of view and find out why they are so angry. I’d sincerely apologize to them if I did anything to cross a line.

At the end of the day, I like to look myself in the mirror and know that I have done the best I can for each of my patients. I am very passionate about my profession, care immensely about the well-being of each patient and believe in evidence-based medicine – not fads and or snake oil. I also hold true to my practice’s slogan – Access, Advocacy, Compassion and Prevention.

I spend a great deal of time in face to face meetings with my patients. I return all phone calls, call regarding all test and lab results and; usually I am aware when a patient is unhappy or dissatisfied.  If I am not aware, my office supervisor or staff know it and bring it to my attention so I can discuss the reason and clear the air or rectify the problem.

If quoting the medical literature to patients to explain a point of view, plus relying on years of experience, is being full of myself; I guess I am guilty.  If I do not respect the wishes of the family when the patient is fully competent to make decisions and is still the legal health care decision maker, than I am guilty as well.

When a patient chooses to leave my practice, I make it a point to send them an individual hand -written note.  I apologize for not meeting their needs and expectations and ask them to please let me know their grievances for the sake of improving the care and service and not repeating actions which a patient found to be negative. I ask “why” they left and if I did something that I should not have done, or did not do something that I should have done. After writing these notes, I have my office staff review them to make sure the tone and content are caring, inquisitive and appropriate.  Unfortunately, no one ever responds.

My friend, the practice advisor, felt it was important to identify these situations and try to further identify the author of each review.  He recommended, and I wholeheartedly agreed, it would be important to have a conversation with each of them to gain a better understanding of the situation, apologize and make any appropriate practice changes.

Since my staff and I are not able to put the pieces of these puzzles together, I am at a loss for identifying the authors.  Furthermore, these online sites do not typically allow a physician to confirm the author was, in fact, a patient and then respond to their review.

That’s a problem since 80% of patients who are seeking a new physician search online.  My advisor has shared with me countless examples of negative physician reviews where there was nothing to indicate the author had ever even been a patient of the practice.

A few years ago I experienced that myself on Angie’s List.  Fortunately, I was able to track down and contact the author and they admitted they and their spouse had never been my patients.  It was an error on their part which reflected poorly on me.  It took time and effort but we were eventually able to have the review removed.  That rarely happens.

If you are a patient who feels you have a gripe with your doctor, I urge you to call that physician or write that doctor and express your concerns and give them a chance to respond. Do that even if you wish to move on. It’s the only way a practice and doctor can improve.  We really do care.

And, if you are seeking a new physician, do not take online reviews at face value.  Gather as much information about the physician as possible and ask if you can have a short meeting with the doctor before making your choice.  That’s something that’s something I make available at my practice for anyone interested in concierge medicine.

Cipro, Levaquin and Tendon Rupture

For many years, fluoroquinolone antibiotics such as Cipro and Levaquin have been integral components of treating bacterial urine infections, travelers’ diarrhea, skin infections and certain pulmonary infections.  Like any chemical or medication, they do not come with a “free lunch.”  There have always been potential side effects and adverse effects possible, in addition to drug to drug interactions with other medications, the prescribing physician needs to take into account before suggesting these products to patients.  In recent months, the use of these antibiotics has come under further critique from individuals developing unexpected tears of tendons and having an increased risk of rupturing a major blood vessel such as the aorta.

The subject of fluoroquinolone antibiotics and tendon rupture was addressed in a recent study of the United Kingdom Clinical Practice Research Datalink and discussed in the on line journal MPR.  They looked at 740,926 users of fluoroquinolone (FQ) antibiotics and tendon ruptures. Of that group, only 3,957 cases of tendon rupture were reported.  This correlated to a risk of 3.73 events per 10,000 person years with an even lower risk for Achilles tendon rupture of 2.91.

When they then looked at which patients with rupture were additionally taking corticosteroids such as prednisone they found the risk increased to 21.2 per 10,000 PY.  The study showed that females were more likely than males to develop a tendon rupture and those over 60 years old as well.

Cipro and Levaquin can certainly remain part of a treatment plan as long as we realize that patients taking steroids, especially women and patients over 60 years of age, are at higher risk than others. That risk, however is extremely small.