Lung Cancer Screening is Underutilized

Dr. Jinai Huo of the University of Florida (Go Gators!) presented data to Reuters Health that primary care physicians are under-utilizing the technology available to screen for lung cancer. This is a particularly sore topic to me because my associate and I always screened smokers and heavy past smokers for lung cancer with an annual chest x-ray until the United States Preventive Task Force issued guidelines that it didn’t save lives and was not cost effective.  They said, it cost $200,000 in normal x-rays to find one cancer early and it was deemed not worth it.

We actually sold our chest x-ray unit, let go our certified radiology technician and cancelled a contract with radiologists to read our films because insurers stopped paying for chest x-rays after the USPTF ruling.  Twenty years later that same group said “woops” an error was made. The statistical analysis on that study was done incorrectly and actually screening does save lives and is cost effective.

Today we have the fast low dose CT scanner to screen for lung cancer and screening does save lives according to the data.  Who should be screened?

Current smokers or those who have quit smoking within the last 15 years who are 55 to 77 years old and have a smoking history of 30 packs or more per year (one pack per day for 30 years or 2 packs a day for fifteen years).  Screening should be done on individuals in good health so if a lesion is found they are considered well enough to undergo diagnostic tests and treatment.

Screening is also recommended in those individuals over 50 years old with a twenty (20) pack year smoking history and a family history of lung cancer or lung disease or occupational exposure to items associated with causing cancer such as radon.

I inquire about smoking at each visit and have been fortunate in that few of our patients still smoke so we spend less time on counseling for smoking cessation.  If you fall into one of the screening groups mentioned in this article, and have not been screened, please notify us so we can arrange for the testing which will be a low dose chest CT scan.

March Is Colon Cancer Awareness Month

Colon CancerColon Cancer is still the second leading cause of death from cancer in the United States despite numerous advances in screening and early detection. It is a disease that is found more commonly in black Americans with 46.7 cases per 100,000 individuals as compared to 38.9 cases per 100,000 individuals for Caucasian Americans. Death from colorectal cancer occurs in every 21.1 cases for African Americans and only 14.6 cases for white Americans.

Even with these dismal figures the cancer death rate from this disease has decreased by 22 percent over the last decade. We attribute this to increased awareness and increased screening.

All individuals should report a change in bowel habits to their doctor immediately. Blood stained stool is a cause for an immediate call to your physician. Generally at age 40 all adults should be having a digital rectal examination as part of a checkup. Stool occult blood slides or stool fecal immunoglobulin slides are used to screen for microscopic gastrointestinal tract bleeding. These tests involve placing a small smear of stool on a slide and submitting it to the lab where it is tested for microscopic blood loss. Usually a CBC or complete blood count is performed as well since gastrointestinal blood loss in small constant amounts usually produces a low blood count or anemia of the iron deficient variety.

Screening colonoscopies are recommended for all non-Black Americans at age 50. Due to the increased risk of colon cancer in Black Americans we recommend that they start screening colonoscopies at age 45. If you have a first degree relative who had colon cancer or precancerous polyps we ask that you start your screening at an age that is 10 years earlier than your relatives disease became apparent.

For those individuals unwilling to have a screening colonoscopy we can offer a CT Virtual Colonoscopy. The preparation is simpler than for a colonoscopy but the radiation dosage involved is equivalent to receiving ten years’ worth of chest x-rays all at once. If the virtual colonoscopy shows a polyp or a mass you will then need to undergo a traditional colonoscopy for biopsy and removal preceded by a traditional pre- colonoscopy bowel cleansing prep.

Cologuard is a new and attractive stool test that detects abnormal DNA associated with premalignant polyps and cancerous tumors. It is fairly new but readily available.

Numerous lifestyle choices can influence your development of colon cancer. Tobacco use is associated with an increased risk, as is drinking more than moderate alcohol. Red meat intake is associated with an increased risk of colon cancer with a 20% increase per 100 gram increase in red meat per day. Regular exercise and intake of high fiber food helps to decrease your risk of developing colon cancer.

March is colon cancer awareness month. Speak to your physician about your risk of developing this serious disease and ways to prevent it from developing. You can use the visit to establish your own personalized colon cancer screening surveillance schedule.

Tiny Sensors to Monitor Medicine Intake Internally

Ingestible SensorsProteus Digital Health is in the process of fine tuning small BB size sensors that you swallow. They are called ingestibles and are activated when they come in contact with saliva or gastric digestive juices. They send signals to monitors, the size of band aids, worn on your chest. From there the data is sent via your smartphone or computer to those health care professionals you designate to receive the data.

The data can include whether you actually took the medicine or not and have developed appropriate blood serum levels, while also monitoring blood sugar levels, blood chemistries and other vital signs. These devices are designed to assist our growing senior citizen population and their care givers up to date on whether you are actually following the prescribed therapies and are they effectively working.

Ingestible chips are now being fine-tuned and integrated with the British National Health Service and are not yet commercially available here in the USA. In development are tinier chips that will actually be in medication pills and send messages to us via our smart phones that it is time to take your pill. Once the pill has been taken it will record that data and serum levels. If you forget you have taken your medication and go to take a second dosage, it will alert you to the fact that you already have taken the medication. If you forget to take your medication a message will be sent to your cell phone or computer and or health care provider.

Some individuals wonder whether all this data is one more “big brother” invasion of personal privacy. With 10,000 baby boomers turning 65 every day and 90% suffering from at least one chronic illness requiring several medications, we will need to balance the benefits versus the risks in deciding if we wish to participate in these monitoring programs.

Women and Cardiovascular Disease – There is A Difference Between Men and Women

Front view of woman holding seedlingThe American Society of Preventive Cardiology presented an educational seminar recently in Boca Raton, Florida to educate physicians, nurses and health care providers that cardiovascular disease in women can be very different than in men.  Failure to recognize these differences has resulted in women being under diagnosed, under treated and suffering worse outcomes.

The difference is first noticeable in pregnancy when the development of elevated blood pressure, super elevation of lipids and the development of gestational diabetes predispose young mothers to earlier, more serious, cardiovascular risk later in life. The faculty noted that women of child bearing age tend to use their obstetrician as their primary care doctor.  They suggested that women with pregnancy related diabetes, hypertension and lipid abnormalities should be referred to a medical doctor knowledgeable in preventive cardiology, post-delivery, for ongoing care.

For reasons that are unclear, women are less likely to be treated to recommended guidelines for lipids, diabetes and hypertension.  Diabetic women have a far worse prognosis with regard to cardiovascular disease as compared to men. They are less likely to be treated with aspirin, which while not as effective in preventing MI in women, is apparently protective against stroke.

Women about to have a heart attack have different symptoms the weeks, to months, before the event. They are more likely to have sleep disturbances, unexplained fatigue, weakness and shortness of breath than the standard exertional angina seen in men.   When they do have a heart attack they are as likely to have shortness of breath and upper abdominal fullness and heartburn as they are to have chest pain. They are more likely to have neck and back pain with nausea than men are.  

Since women have different symptoms than men they are more likely to be sent home from the emergency room without treatment.  They are less likely to have bypass surgery than men, less likely to be treated with the anticoagulants and antiplatelet medications that men are treated with and, they are less likely to be taken to the catheterization lab for diagnosis and intervention as compared to men.

The faculty was comprised of world-class researchers, clinicians and educators who happened to be outstanding speakers as well, bringing a vital message to our community.  They pointed out the different questions and diagnostic tests we should be considering in evaluating a woman as opposed to a man.

This was my first educational seminar through the American College of Preventive Cardiology and I thank them for the message they delivered to the medical and nursing community at probably one of the finest seminars I have had the privilege to attend.

Squamous Cell Skin Cancers Can Kill

Skin CancerAs part of my office visits, I routinely question patients about health checkups and benchmarking. We talk about eye exams and glaucoma. We talk about women’s health issues and gynecologic exams plus mammograms and bone densitometry.  We talk about colon cancer screening and colonoscopies and immunochemical fecal occult blood slides.  We always ask about skin and whole body checkups with a dermatologist or a primary care physician.

Patients often ask me why I am constantly harping on looking at these issues. “I am old and have survived quite well without these checkups until now.”  

Florida is my home state and it is in the extreme Sun Belt and one of the skin cancer capitals of the world. MedPage Today, the University of Pennsylvania online journal justified my questions about skin cancer and skin exams by publishing a synopsis of Chrysalyne D. Schmults, MD and associates at Harvard University publication in the May issue of JAMA Dermatology.  They reviewed the pathology reports of skin cancer from Brigham and Women’s Hospital in Boston from 2000 through 2009 identifying 1,832 tumors in 985 patients. More than half of the patients were men, most were Caucasian and a suppressed immune system was present in almost 15%. Tumor diameter was less than 2cm (2.54 cm equal an inch) in 85%, was well differentiated in 66% and the tumor was limited to the upper skin level or dermis in 89.5%. The most common locations were the head and neck (28.7%), the legs or feet ( 23.7%), and the hands or arms in 21.6%. Treatment included standard excision in 69.5% and Moths Surgery in 20.2%

Analysis for spread to the lymph nodes, local recurrence, or death due to the disease directly or indirectly seemed to be related to certain factors.  Age over 70, male sex, poor tumor differentiation and perineural invasion all were considered poor risk factors. The death rate from the squamous cell skin cancer approached 3%

The data reviewed in this study will allow researchers to design evaluation and surveillance protocols for high risk skin cancer patients. Until now, no study actually defined what characteristics comprised a high risk skin cancer patient.  

As we head into the summer season it is a reminder of the need for us to use SPF 30 or greater sunscreen on all exposed areas and reapply liberally. Wear wide brimmed hats and clothing with a tight weave to protect your skin. Above all, see your board certified dermatologist for a whole body skin checkup regularly to prevent the growth and spread of a preventable killer disease.

Cervical Cancer Screening Guidelines – American College of Obstetricians and Gynecologists

Cervical Cancer Screening - Steve Reznick, M.D.On a routine basis my female patients, many of whom have undergone a total hysterectomy, ask me if they need to continue to have Pap smears annually. There has clearly been a great deal of confusion about who should get a Pap smears and when. This communication is an attempt to clear that up.

1. Women who have had a hysterectomy and removal of the cervix (total hysterectomy) and; have never had an abnormal Pap smear (graded a CIN 2 or higher – cervical intraepithelial neoplasia), do not require a Pap smear. If they are still getting them they should be discontinued and never restarted

2. Screening for cervical cancer by any modality should be discontinued after age 65 years in women with evidence of adequate negative prior screening ( 3 consecutive negativ pap smears with the most recent having been done within 5 years and no history of abnormal Pap smears graded CIN 2 or higher).

3. Cervical cancer screening should begin at age 21 years. Women younger than 21 years should not be screened regardless of the age of initiation of sexual activity or the presence of other behavior related risk factors.

4. Women aged 21-29 years should be tested with cervical cytology alone. Screening should be performed every 3 years

5. Women aged 30-65 should have “co testing with cytology and human papillomavirus (HPV) testing every 5 years.

6. In women aged 30-65 years, screening with Pal smear cytology every 3 years is acceptable. Annual screening is not preferred.

7. Women who have a history of cervical cancer, have HIV infection, are immunocompromised, or were exposed to diethylstilbestrol in utero should not follow these minimal routine screening guidelines.

8. Both liquid-based and conventional methods of cervical cytology collection are acceptable for screening.

United States Preventive Care Can Be Better, Center for Disease Control Says

Ralph Coates, PhD of the Center for Disease Control (CDC) described in the June 15, 2012 issue of Morbidity and Mortality Weekly Report that by looking back at a U.S. study done between 2007-2010 called “Use of Selected Clinical Preventive Services among Adults,” health providers need to do a more comprehensive job of offering preventive services.

According to the report, only 47% of patients with documented heart and vascular disease were given a recommendation to use aspirin for prevention. They additionally found that only 44% had their blood pressure under control. When looking at cholesterol and lipid control only 33% of the men and 26% of the women were tested with a blood lipid test in the last five years.  Of those patients who did measure their lipid levels, only 32% of the men and women surveyed had their lipids under control. Among diabetics, 13% had poor sugar control with a HgbA1C > 9 (goal is 6-8).

The data indicate that at 37% of the visits, patients weren’t asked about their smoking or tobacco status.  When patients were asked, and answered that they were smoking, only 21% were given smoking cessation counseling and only 7.6 % were prescribed medications or a way to stop smoking.

Screening for cancer needs improvement as well. Twenty percent of women between the ages of 50-74 had not had a mammogram in over two years.  In the same age group, a third of the patients were not current on screening for colon and rectal cancer.

The data was collected prior to the passage of the controversial Affordable Care Act. When the data was analyzed and divided according to socioeconomic status, education level, and health insurance status; it was clear that the poorest and least educated had the fewest screenings. It is hoped that with passage of the new health care law, and new insight by health insurers that it is cheaper to prevent a disease than treat it, these numbers will improve.

There are several other factors that need to be looked at as well. Data is now being collected from electronic medical health records.

I ask my patients about tobacco status on every patient visit.  When I note that the patient is smoking in their electronic health record, there are three or four ways to document counseling has been offered. Only one of them triggers the audit data for the government to review. Our software instructors were unaware of that when they taught us to use the system.  How much of this study is the result of data collection error is unknown.  “Health care providers” – not just physicians, are now delivering health care.

Access to physicians and a shortage of primary care physicians exacerbate the problem. It takes time to extract this information, record it, and counsel the patient. Because PCPs are underpaid, they will continue to see patients in high volumes to cover their expenses, causing the use of comprehensive preventative questioning to remain low.