– by Dr. Irving Loh, MD

An interesting article (1) last month in Circulation: Cardiovascular Quality and Outcomes quantified something that has been quite subjective for experienced clinicians when dealing with coronary heart disease patients. When objectively diagnosed with stress and depression, CHD patients had a 48% higher risk of increased MI or death in 2.5 years of followup compared to the low stress and depression cohort. As a profession, it looks like we’re all in big trouble.

This study came out of Columbia University in New York and was lead by Dr. Carmela Alcántara. They examined the profiles of 4487 patients aged 45 or older enrolled in the Reasons for Geographic and Racial Differences in Stroke study and thus were known to have coronary heart disease. From 2003 to 2007, patients were interviewed at home or asked by questionnaires how often during the past week they felt depressed, lonely or sad, or had crying spells. They were also asked how often they felt unable to control important things in their lives, felt overwhelmed, felt confidence in their ability to handle personal problems and felt things were going their way during the past month. The implications of unrecognized or inadequately treated stress and depression can be manifested internally by adverse cardiovascular outcomes or externally as with the co-pilot of the Germanwings tragedy last month.

It was determined that it was the interaction between self-reported stress and depression, rather than just each independently that seemed to be related to the outcome measures, though no clear causal mechanism was discerned. Each of these symptoms separately did not seem to increase risk. Segregation of these factors as clinicians know is hardly a clean science, so their cohabitation in an affected patient is enough to warrant more focused attention on not only the patient’s cardiovascular risk factors, but on mitigating the psychosocial exacerbation of major cardiovascular adverse event risk. We all know about the sophisticated lifestyle and pharmacologic strategies needed to manage the classic cardiovascular risk factors. This study suggests that there may remain significant gaps in psychosocial care that may have similar implications for clinical outcomes. Indeed, coronary heart disease is a process that trends in the older population, and there are inadequately addressed issues in both the medical and sociological arenas that can alleviate the stress and depression that disproportionately afflict the elderly.

A multidisciplinary team approach with targeted care coordination is needed. Our society generally and our healthcare system specifically are not well prepared to effectively manage this scenario, but with a potentially manageable 50% increased risk, perhaps we need to implement concepts like care circles and care coordination tools like Tiatros™ (reader warning: I am a Tiatros™ advisor, so it’s one with which I am familiar, but there are other similar programs as well so no product endorsement should be interpreted or implied) that can help alert the care giver team. More research is required to determine mechanisms and optimal interventions to positively effect outcomes.
References:

1. http://bit.ly/1B1S14d Circulation: Cardiovascular Quality and Outcomes, online March 10, 2015

Bio:

Dr. Irving Kent Loh MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.

The post Stress and Depression Increase Heart Risk appeared first on Sermo.

~ by Linda M. Girgis, MD

We have started to explore the complications obesity can cause. This post will look at its association with sleep apnea. The role of obesity in sleep apnea has been well established in adults and children alike. Its rate has been climbing.

The prevalence of OSA in obese patients is nearly twice that of normal weight patients. Patients with mild OSA who gain 10% of their baseline weight have at a sixfold-increased risk of progression of OSA.  Similarly, a loss of an equal amount of weight can lead to more than 20% improvement in OSA severity. Some recent studies show that obese children have a 46% prevalence of OSA when compared with children seen in a general pediatric clinic (33%).

Why does obesity cause OSA?

It is felt that deposits of fat in specific areas play a key in determining whether someone develops OSA. For instance, fat deposits in the tissues surrounding the upper airways can result in a narrower lumen and increased collapsibility of the upper airway.  In addition, truncal obesity reduces chest compliance, functional residual capacity, and increased demand for oxygen.  Nevertheless, the relationship between OSA and obesity is much more complex.  Patients with OSA tend to have reduced physical activity and cravings for carbohydrates that tend to exacerbate the obesity.  CPAP has been shown to reduce the visceral fat in some patients.  There have been some studies showing an interplay of obesity and OSA as a result of genetic factors, specifically polymorphisms of the leptin receptor.

It is even more alarming that we see  this more frequently in children and adolescents.  In one study, 46 children were evaluated. These subjects were recruited from a pediatric obesity clinic at a university hospital. They had been referred there by their primary care providers. They were compared to 44 normal weight subjects who were matched for other characteristics, such as sex and age.  This study showed that mild breathing disruptions, however, they were more significant in obese subjects. It was also shown that many of them had enlarged tonsils and adenoids, so suggested ENT consult in cases of OSA in children despite their BMI. An interesting observation in this study is that oxygen desaturations were not as severe as in adults with OSA and, therefore, children with OSA did not suffer from daytime sleepiness as much.

The Sleep AHEAD study showed that there was a clear improvement in OSA in patients who lost weight.  This study included 264 subjects in 4 different centers.  Their average BMI was 36.7 and average apnea-hypopnea index (API) 23.2 events per hour. This study showed that clearly weight loss improved OSA, especially in men and those with higher AHI scores.   In patients who maintained their weight for one year, they maintained their benefits of their weight loss as evidenced by their repeated AHI scores.

Obesity clearly plays an etiologic role in OSA in both adults and children. We are learning the dangers of OSA as time goes on, in terms of hypertension and cardiovascular disease.  While obesity itself has a clear cause of producing OSB, it appears to be multi-factorial. Weight loss has been clearly demonstrated to improve OSA in many studies. The treatment should start with lifestyle changes and weight loss.

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

Bio

Dr. Linda Girgis MD, FAAFP is a family physician in South River, New Jersey. She has been in private practice since 2001. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. She teaches medical students and residents from Drexel University, UMDNJ, and other institutions.  Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University.  She has appeared in US News and on NBC Nightly News.

The post Obesity and Sleep Apnea appeared first on Sermo.

A recent SERMO poll found 92 percent of doctors think the current measles outbreak is directly attributable to parents who do not vaccinate their children.  Further, a physician poll conducted in August 2014 found the majority of doctors think unvaccinated children should not be allowed to attend public schools.

Public health officials agree, last week a California high school barred 66 students from attending school for not having the MMR vaccine when a suspected measles case appeared in the study body.

Measles Infographic

Our infographic shows the importance of a measles vaccine, and its impact on patients.  A recent discussion inside SERMO talked about the problem. One internist wrote, “It is dangerous for every other patient in your practice. An anti-vax kid brought in by a parent for a rash sitting in the waiting room of a busy pediatric practice could spread measles to countless others in a matter of minutes.”

Some doctors believe seeing non-vaccinated patients is an opportunity to educate. An OBGYN wrote, “We have a large community of anti-vaxxers in my state, and it would be difficult to refuse them outright. Instead, I use persuasion to try to educate them and make my advocacy position very clear. I have had some limited success with this tactic.”

The American Academy of Pediatrics has urged doctors to respect each patient’s preferences but continue to educate about vaccinations unless there is a heightened medical issue for getting a vaccine.

What do you think about vaccinations and the current measles outbreak?  Should unvaccinated children be banned from public schools?  Should doctors urge patients to get vaccinated and turn away those who refuse?  If you’re an M.D. or D.O. you can join the conversation right now inside SERMO.

The post Measles Infographic on Current Epidemic appeared first on Sermo.

Announcing our new Hubs: Neurology & Allergy and Immunology

Today, SERMO is excited to announce two new additions to our growing family of informational Hubs. Hubs are centered around specific disease states or specialty areas.  This is part of our commitment to bring you up-to-date, clinical information to our physicians.  The new hubs are:

• Allergy and Immunology
• Neurology

Physicians who specialize in these two areas will now have the appropriate Hub as their home page.  The Hub includes weekly expert articles written by peers,  focused polls and videos.  This means a neurologist will be able to view the Neurology Hub right on their member homepage.

Hubs are led by physician peers with, over 45 physician writers providing top-flight discussion topics, research, and authoring polls for fellow members. They’ll be discussing the latest research, trends in your specialty and clinical best practices.

These HUBs unite the best of what Sermo offers in a collaborative space that includes:

• Specialty or disease-focused polls
• A Multimedia Channel for the latest related video content
• Fresh, breaking posts from your Sermo peers
• An inside look into related discussions on Twitter
• New research, resources, and upcoming conference updates

If you are an M.D. or D.O. you can join the SERMO physician community and interact with your peers immediately.  Membership is free and all physicians are verified.

Interested in the other Sermo Hubs?  Visit them now.

• Multiple Sclerosis
• Oncology
• Diabetes
• Cardiology 
• Obesity
• Infectious Diseases
• Depression
• Bipolar Disorder
• Dermatology
• Pain Medicine
• Rheumatoid Arthritis
• Gerd
• Asthma 

We wanted to thank our physicians for creating such an active, vibrant community.  Approximately 60 percent of our content is clinical in nature.  One of our most used features is SERMOsolves, an app doctors use to upload patient information and collaborate on diagnoses and treatment plans.

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~ by James M. Wilson V, MD

Media reports have recently focused on CDC statements indicating we are having a “severe” season of influenza. This concern was initially driven by the discovery of a vaccine mismatch involving the type A/H3N2 component of the vaccine. We have discussed this issue extensively in previous posts here on SERMO and emphasized the following points:

• The phrase “vaccine mismatch” does not guarantee a severe season of influenza. The current 2014-15 season is comparable to the activity seen in 2012-13, a non-mismatch season.
  The main exception of concern is the elderly, which will be discussed in this post.
• That vaccine mismatch associated with a dominant A/H3N2 season is common and not unexpected.

The term “severe” is imprecise. It is as imprecise as the terms pandemic, epidemic, and outbreak in today’s public health discourse. At the Ascel Bio National Infectious Disease Forecast Center, we use terms that describe the level of socio-economic disruption to a community that are captured in the Infectious Disease Impact Scale (IDIS).

Figure 1. The Infectious Disease Impact Scale (IDIS). From top to bottom, this scale is a heuristic model that describes the transition points of socio-economic disruption experienced by a community in the context of an infectious disease outbreak or epidemic.

We use the IDIS to provide a “bottom line,” high level view of infectious disease activity and are using this analytic tool to describe the effect of Ebola on the core involved countries in West Africa:

 Figure 2. Signature tracing of socio-economic disruption caused by Ebola over time in Sierra Leone. The X axis is the day, going back to the beginning of the disaster. Ebola has generated persistent IDIS Cat 6 conditions for months in Sierra Leone.

The best analogy for the IDIS is a comparison to the Fujita scale, which is a heuristic model used to describe the magnitude and potential impact of tornadoes. The IDIS is an important tool for our analysts because an “epidemic” of disease in one country may be described an “epidemic” in another- but be associated with completely different IDIS categorizations that relate to that country’s medical infrastructure and response capacity.

Currently in the United States, we have yet to document a community experiencing more than IDIS Category 2 conditions for influenza. Despite media attention, we are not observing unusual socio-economic disruption levels.

There are reasons for these observations. First, let’s take a look at the current surveillance data from this year’s influenza activity.

From a pediatric (i.e. birth to 18 years old) perspective, we are seeing a routine season of influenza in our younger birth to 4 year old children, but high activity in the 5-17 year old age group.

 Figure 3. Influenza hospitalizations in the pediatric age group. The Y axis on the left corresponds with
incidence for prior seasons except the pandemic season of 2009-10, where children were severely effected. Pandemic incidence is read on the right hand Y axis associated with the orange trend line. [Data source: CDC FluView]

Figure 4. Pediatric mortality due to influenza. This is the true bottom line for severity from a clinical perspective. We are not seeing an unusual level of mortality so far in the pediatric patient population compare to prior seasons. The main caveat is mortality data is delayed sometimes by weeks, so a final assessment at the conclusion of the season (i.e. in the summer) will be required. [Data source: CDC FluView]

 From the perspective of our working age group, which is responsible for maintaining economic throughput for the nation, this continues to be a routine influenza season.

Figure 5. Influenza hospitalizations in the working age group. In this age group, the 2009-10 pandemic season’s impact for the end of December / early January time period was comparable to a routine influenza season. This year’s influenza activity level is routine. [Data source: CDC FluView]

The elderly, however, have been hit hard by this season’s influenza, and this is the key observation for this season that has been called “severe.”

 Figure 6. Influenza hospitalizations in older adults and the elderly. In this age group, the 2009-10 pandemic season was not severe at the end of December / early January. What is notable is the 2014-15 season is associated with the highest level of hospitalizations in this age groups since before the pandemic. [Data source: CDC FluView]

 From the perspective of overall mortality due to pneumonia and influenza, this season is routine, however the data is still being compiled and will require re-examination in early summer.

Figure 7. Overall mortality due to pneumonia and influenza. So far, mortality appears to be comparable to all prior seasons of influenza. Caveat: there are inherent time delays in reporting of mortality data, so this information should be interpreted with that in mind. [Data source: CDC FluView]

In summary, we observe the following:

• The current influenza season overall is not “severe” and is comparable to the prior two years of seasonal activity. We observe no higher socio-economic disruption than IDIS Category 2 (non-crisis) conditions.
• For older adults and the elderly, this is a severe season.

One last point of importance: the concern about a “mismatched” vaccine. The majority of America, including its physicians appear to hold a belief that the vaccine is “useless” because mismatch has occurred. Yet both WHO and CDC continue to recommend the use of the vaccine. It is critical to keep in mind the following key points:

• The vaccine, while mismatched, is not fully. In other words, there remains a probability the vaccine will keep an individual out of the ICU or from dying.
• Patients should question a physician who does not offer the influenza vaccine, despite the mismatch. Physicians should offer the vaccine to patients regardless of the observation of a mismatch. If anything, observation of a “mismatch” is a major warning to society to encourage even broader vaccination than is normally done.
• Tamiflu may or may not save your life if you are hospitalized with influenza. Tamiflu is considered by the majority of physicians to be of questionable value when a patient has been ill for several days and later hospitalized. The bottom line is don’t depend on Tamiflu to save your life if you choose not to vaccinate.

Biography

Dr. James Wilson, a pediatrician and infectious disease expert with AscelBio, he is a frequent contributor to the SERMO blog.

Season flu and it’s movements in the US are discussed frequently inside SERMO.  If you’re an MD or DO please join us for the latest news shared by your peers.

The post Influenza Update: 2014 – 2015 flu season changes appeared first on Sermo.

Does air pollution cause autism?

As we settle into 2015, quite a few announcements and research results are making waves this week.  Let us know which stories piqued your interest.

Autism and Pollution

A new study released this week from the Nurses Health Study II cohort looked at over 113,000 women around the issues of autism and pregnancy.  Researchers found a correlation between air pollution particulate during pregnancy, particularly during the third trimester, and children later developing autism.

3D Printing Preps Surgeons

In two separate cases, patients created 3D images to guide surgeons before the surgery took place.  A man in England printed out his kidney to help his surgeon pinpoint and remove a kidney stone.  A female patient was facing a tricky removal of a tumor above the eye.  Her husband printed and shipped a 3D image of her skull with the tumor to help surgeons prep for what turned out to be an innovative, minimally invasive procedure.  Other medical centers are catching on and we think this could be widespread soon.

Wounds Monitored by Smart Phone

Wounds don’t always heal properly.  Currently, the only way to monitor healing, is to unwrap the wounds and poke, even smell, the area for signs of infection.  Researchers at Mass General Hospital developed a “smart bandage” that is painted on the injury site and measures oxygen levels.  If oxygen levels are low, the bandage will show the area in red, indicating further medical assessment.  The best part, a doctor can check in via smart phone without needing to see the patient.

Head of Medicare/Medicaid Stepping Down

Marilyn B. Tavenner, the head of Medicare and Medicaid will be stepping down in February.  Tavenner oversaw the roll-out of the ACA including the complete botch of the federal insurance signup site.  The White House has not named a replacement.  Do you think Tavenner leaving is good for Medicare/Medicaid?

Assaults Against Doctors Common

We made the news this week when we released poll results from over 2,000 physicians.  Seventy-one percent of doctors reported being the victim of either verbal or physical assault.  The SERMOpoll sparked discussion on social media; many health care workers talked about their experiences.  How would you limit assaults on health care workers?

Physicians constantly share the latest research and medical news inside SERMO.  If you’re an M.D. or D.O., please join us; membership is free.  We are the most influential physician community in the U.S.

The post Medical News Roundup: Great tech and a big political move appeared first on Sermo.

The post 2014 – 2015 Flu Season: An Update appeared first on Sermo.

Every year, an estimated 42.5 million Americans suffer from some condition linked to mental illness. One could surmise the growth of mental illness reports have risen due to the radical transformation of the relationship between mental illness and its acceptance in society over time.

So how far back can we track mental illness and how was it treated?

Early History

• Prehistoric times: Mental illness was believed to stem from magical beings and rituals were used to treat these sick people. One of the most primitive ways of dealing with the mentally sick was a procedure called trepanation where a hole in the skull was created using a sharp object, usually a bone. It was believed to release the evil spirits trapped inside curing the afflicted person.

• Ancient Egypt: The Egyptians believed mental illness was caused by the loss of power or status. They believed the cause of the illness lie within the subconscious and would use opium to stimulate visual dreaming.

• 400 B.C: There were differing explanations of mental illness during this time from philosophers. Many believed it was a gift or curse from the gods and with no treatment. Hippocrates, however, believed mental illness was caused by physiology. He suggested simple changes to a person’s diet, and physical surroundings would cure them.

• Middle Ages: Displeasure of the gods and sin were the root causes for mental illness during this time. Causes of illness ranged from witchcraft to demonic possession. For demonic possessions, the patient would be immersed in scalding hot water in an effort to draw the demon out of the body. Women accused of witchery were burned at the stake.

• Victorian times: Gender bias was experienced fairly often in Victorian times. Menstruation, pregnancy, post-partum depression, disobedience, chronic fatigue, or anxiety could cause women to be seen as unbalanced and labeled as hysteria. These women were then placed in institutions, sometimes for the remainder of their life.

Treatment or Torture?

From the middles ages to the 1800s, the mentally ill were hidden away from society in institutions. Most patients taken to institutions were there to be forgotten and not cured. Behind the walls of the institution, patients were not treated as humans in need of help but prisoners. The rooms that housed patients were jail cells with patients chained to walls, sometimes overcrowded and covered with feces. Bedlam Institute, London’s first asylum for the mentally ill, over the centuries has made a name for itself as a leading example of how the mentally ill were mistreated. For one penny, onlookers could visit the asylum and poke patients through their cells with long wooden sticks.

Gawking at patients as if they were animals was just one form of mistreatment. Their treatment methods are considered inhumane today.

• Red hot pokers: Patients were branded or poked with a red hot iron to bring them to their senses.
• Hydro-therapy: Patients stood in a narrow shower while being sprayed by cold water from a hose to stimulate them.
• Insulin therapy: Used on patients with schizophrenia. The insulin would drop the patient’s blood sugar placing them into a coma and brought on convulsions and brain seizures. Glucose shots either injected or given through nasal passages were used to bring the patients out of their coma.
• Lobotomy: A brain operation where the cortex of the brain’s frontal lobe was disconnected from the lower centers of the brain. This was normally down by sticking a long needle through the eye of the patient. If the procedure was done incorrectly, the result could be death.

Some of these treatments continued on through the 1970s.

Advancements in mental illness

If you’re an M.D. or D.O. visit our BiPolar Hub for resources and to collaborate with colleagues

During a time when mental illness was not prioritized in medicine, two women fought for a change. In the 1840s, Dorothy Dix observed the mentally ill in a Massachusetts institute where she conducted interviews with patients. She documented the treatment of the patients she saw in a piece she wrote to the General Assembly of North Carolina. Her argument was the mentally ill should not be thrown away but committed to institutions devoted to mental health and understanding it’s causes. Over 40 years, she helped to establish 32 state institutes.

Another woman who brought to light the mistreatment of the mentally ill was reporter, Nellie Bly. In an assignment for the local paper in the 1880s, she committed herself to one of the largest institutions in New York as a mentally ill woman where she stayed for ten days. When her story was published, she exposed the mistreatment she experienced and the filthy conditions of the institute. Her story brought attention to the public and politicians bringing in reform for institutions.

It wasn’t until the 1900s that experts began to try and understand the peril of mental illness. During this time, Sigmund Freud proposed the idea of the unconscious. He believed some people had thoughts so upsetting they were buried deep in a person’s subconscious. His practice, known as the “talking cure,” was widely debated then and still to this day.

In the 1940s-50s, the use of medication to solve mental illness emerged. Chemists began experimenting with pills that may “calm imbalances inside the brain and deliver relief.”

Modern Day

While there is still stigma around mental illness, there are many options for help. The mentally ill are not hidden away, but institutions exist to treat and understand their plight. Psychologists offer “talk therapy” while psychiatrists offer talking as well as prescriptive medication if needed. Organizations like the National Alliance on Mental Illness dedicate their cause to bettering lives for those affected by mental illness as well as educating others about illnesses.

As a physician, do you believe there is still a large negative stigma toward mental illness? What do you think are the biggest issues facing mental illness today? If you work in this field, we would love to hear from you.

We will be discussing this and more inside Sermo, our physician community. If you’re an M.D. or D.O., please join us.

Sources:

1. Treatment of the Mentally Ill
2. The 10 Worst Mental health Treatments in History
3. A Short History of Mental Health
4. History of Mental Health Treatment
5. Timeline: Treatments for Mental Illness
6. Early Treatment of Mental Disorders

The post Mental Illness in America: Before the happy pills appeared first on Sermo.

Silicon Valley is clamoring to enter the medical, wearable tech niche.  Every tech company from Apple to Google is trying to solve our health crises with some kind of tracker, some simple, some sophisticated.

Sandy Pentland, PhD., of the MIT Media Lab has been tracking individuals by smart phones and other devices for years. He has gleaned a theory of “Social Physics” that can track and predict behavior and even foresee disease and illness. We had the chance to talk with him about his intriguing research and how physicians can apply it to their patients today.

~ Video Introductions by Ayesha Khalid, MD, MBA, Enterologist

Social Physics and Obesity: In the healthcare world, we have a hard time motivating our patients to follow the plans and pathways we create as doctors. If we can find the right incentives to get people to change their behavior and keep it that way- bingo! Huge win!

Pentland addresses this in a pilot health program. Participants received incentives whenever a person they partnered with worked out.   This buddy system was eight times more effective per dollar than normal financial incentives. More importantly, they kept up the social network and exercise guidelines after the experiment concluded.

Social Physics and Genetics: The power of social physics and thinking about the spread of ideas can be very powerful in health care. Disease groups such as depression may be haphazardly grouped based on an accidental clustering of symptoms. Pentland discusses why therapeutics work so differently on individual diseases within a category. One recent project adds a behavioral and phenotypic component to genetics data and starts to tease out the different types of diabetes, or depression.

Social Physics and mental health: Imagine a world, where soldiers who have PTSD provide their psychiatrist with daily updates via their smart phones. Physicians don’t have to wait weeks for a check-up to see how medication is doing, but can simply check an app to look for tell-tale signs. Changes in behavior, both major and nuanced are tracked relaying a patient’s progression.

Social Physics vs Social Media: Recent media discussed the inaccuracy of “Google flu,” an online tracking algorithm that predicts the movement of the flu virus based on people searching for information. Pentland discusses the difference between aggregated data point from individual tracking vs keyword tracking through social media and search.

Conclusion  

Human beings are highly social and communal in our sharing with one another, a trait signified by the importance of language and sociocultural imprinting. We know that Western healthcare does not pay attention to the power of social dynamics, our external environment, and the role it plays in our own wellbeing. Would it not be interesting if we could measure that in some way and help it to understand the power of the relationship of our genetic makeup with our disease manifestation?

Bios:

Sandy Pentland has been a professor with the MIT Media Lab for nearly 30 years. He is also the co-founder of several companies including ginger.io and Thasos Group. He is the author of two books, Social Physics and Honest Signals.

Ayesha Khalid is a sinus surgeon with an MBA from the MIT Sloan School of Management. Ayesha is interested in the re-design of the health care system with a patient-centered focus, specifically in the area of clinical trials and rare diseases. She is a co-organizer at Hacking Medicine, an interdisciplinary group at MIT that seeks to spark change in healthcare. She also serves as the Young Physician Chair for all ear, nose and throat physicians in the United States.

The post Sandy Pentland Discusses Wearable Tech and Medicine appeared first on Sermo.

~ by Dennis Morgan, MD, Oncologist

There has been much controversy in recent years over just who should get screening mammography. The greatest contention is over what age to begin and how often to perform. Women will understandably bring a certain amount of emotion to the table. Ideally the medical community would bring curated facts to the table that inform a process of shared decision making. The major challenge for all parties involved is the curation process — not just knowing the facts, but making sense of them.

My overview of this subject comes at the behest of someone who recently underwent a harrowing encounter with mammography. As a medical oncologist my perspective is not necessarily neutral as I have an inherent wariness of the “slippery slope” of investigation and intervention that can lead to unintended, sometimes harmful, consequences. But I have no related service to promote or academic position to defend. Let me share my investigation of this controversy and invite comment.

Our first task is to separate fact from opinion. Opinion comes from personal values or professional goals. I would categorize the relevant literature into studies, reports and positions. Studies are original scientific investigations (facts), reports a critical analysis of such studies (interpretation of facts), and positions, i.e. opinions, about next steps. The landscape is dotted with any number of each. The area of hottest contention is the appropriate age bracket for screening. The value of any screening tool depends on the prevalence of the disease. In our case it is relevant the risk is proportional to age. Young women are  unlikely to have breast cancer, and the oldest women are more prone to getting it but also more often die of another condition. So the firestorm is over which of the ‘middle-aged’ women to screen.

Let’s take as our focal point the era before the publication in 2009 of the — infamous to some — U.S. Preventive Services Task Force (USPSTF) Recommendation Statement(1). This update of a 2002 paper is controversial for it’s radical departure from common practice. While supporting mammography for women age 50-74 it advised only a two-year, not annual, schedule. For women younger and older than this the task force was not persuaded of demonstrated benefit. Nor was any confidence expressed for the alternative imaging methods of digital mammography or MRI. Perhaps most shocking was their position that breast self-exam (BSE) is a waste of time and should not even be taught.

The blow back was swift and vehement, notably by The American Cancer Society (ACS) which maintains to this day that “Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s.” Further, “Mammograms should be continued regardless of a woman’s age, as long as she does not have serious, chronic health problems … ”. (2).

And this from a letter in the New York Times by the chairwoman of the Breast Imaging Commission of the American College of Radiology and the president of the Society of Breast Imaging (3):

“Every medical organization experienced in breast cancer (including the American Cancer Society, American Congress of Obstetricians and Gynecologists, American College of Radiology, Society of Breast Imaging and National Accreditation Program for Breast Centers) recommends annual mammograms for women ages 40 and older.”

I think it is notable that every organization cited is either positioned as a patient advocate/protector or is a provider of the service. Perhaps neither would be inclined to retreat from a posture of vigilance.

Their letter was in response to an op-ed piece (4) by a co-author of Quantifying the Benefits and Harms of Screening Mammography — an MD, MPH faculty member of the Institute for Health Policy and Clinical Practice at Dartmouth(5). He cited data from the radiology community itself that the false positive rate for over ten years of annual screening is 50 percent.  He noted, “A screening program that falsely alarms about half the population is outrageous.” and “What about the benefit? Among those thousand women, 3.2 to 0.3 will avoid a breast-cancer death. If you don’t like decimals, call it 3 to 0.”. His paper is, I believe, the most comprehensive and impartial survey to date and is discussed in his interview in the ASCO Post(6).

There is a growing list of studies and reports that recommend a decrease in the use of mammography but the message seems as foreign to the American institutions cited above as the countries originating them.

From Scandinavia 2008 in the Cochrane Database of Systematic Reviews — the Nordic Cochrane report(7):

“If we assume that screening reduces breast cancer mortality by 15% after 13 years of follow-up and that over-diagnosis and over-treatment is at 30%, it means that for every 2,000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings.”

From Norway 2010 in the New England Journal — The Norwegian Breast Cancer Screening Program(8):

“The difference in the reduction in mortality between the current and historical groups that could be attributed to screening alone was 2.4 deaths per 100,000 person-years, or a third of the total reduction of 7.2 deaths …”

From Canada 2014 in the British Medical Journal — 25 year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial(9). Annual mammography screening did not reduce long-term breast cancer mortality in women 40 to 59 years of age. An independent commentary on this study observed that “If the … results are correct, the number of “cured” drops to 0.” (10).

From Switzerland 2013 in the New England Journal of Medicine — Abolishing Mammography Screening Programs? A View from the Swiss Medical Board(11): Tasked with a recommendation for all of Switzerland the panel made several observations.

1. Conventional recommendations are based on outdated trials that do not reflect the effect of modern treatment.
2. It was not at all obvious that benefits outweigh risks when one compares a generally accepted 20% reduction in mortality with a 21.9% rate of over-diagnosis.
3. They note women substantially overestimate the benefits. “It is easy to promote mammography screening if the majority of women believe  it prevents or reduces the risk of getting breast cancer and saves many lives through early detection of aggressive tumors. We would be in favor of mammography screening if these beliefs were valid. Unfortunately, they are not, and we believe that women need to be told so.” “The board, therefore, recommended that no new systematic mammography screening programs be introduced and that a time limit be placed on existing programs.”

Why such resistance to change given the benefits are less, and the risks more than previously appreciated? Evidence contrary to closely held beliefs is always hard to accept and confirmation bias, favoring reports that agree with an a priori position, is hard to avoid. In the case of mammography several forces marshal to stave off change. I would suggest that some combination of emotion, defensive medicine, lack of scientific understanding, and a profit motive are responsible for continued over-use of mammography in the US.

Let’s see if we can tie some of this together with a visit to the doctor’s office. The office staff advises the patient that she is due for screening mammography. Often accompanied by fear and hope the staff reinforces her decision by anecdotes about others whose ‘lives were saved’ by mammography. Her hope is that the result will be negative because she could then conclude that she does not have breast cancer. But this is not necessarily so. On the other hand if the mammogram is positive she would then think that while she does have breast cancer her life will be saved by this early detection. Again, neither of these assumptions are necessarily true.

There are four possible outcomes from mammography — a positive or negative reading, either of which may be true or false. These provide the data for Bayesian analysis that is the mathematical rationale for screening tests.

The false results are instructive as to why screening mammography may continue to be overused. With false positive results, further studies — additional imaging and biopsy — will, hopefully, declare the patient cancer-free after all. The patient is reassured, thankful for the vigilance of her physicians. Unnecessary treatment avoided.

With false negative mammograms the cancer may eventually surface by some other means and, when it does, everyone will have a second look at that mammogram. Assuming it wasn’t read in error (not the same as ‘false negative’), the patient will be told that mammograms miss 20% of breast cancers.  They’ll tell her it was a “good thing she was doing BSE” or good thing that some serendipitous event lead to discovery. The fact that the mammogram in her case was of no value will probably be over-looked.

What’s worse? A breast cancer diagnosis within a year or two of a false negative mammogram or no mammogram at all? The patient is likely to have considerable negative feelings and second guess her physician’s value more than the mammograms. Negative feelings about physicians drives lawsuits. Doctors know this and often practice “defensive medicine” — better to get a test of questionable value than face negligence accusations, no matter how unwarranted.

Doctors often do not understand the limitations of screening tests. Bayesian analysis gives answers that are not intuitive for patients or physicians. Physicians routinely over-estimate the chance of cancer based on a positive mammogram. We are all prone to attaching more significance to relative changes than to absolute values as with the Norwegian study cited earlier. Are we to heed the one-third reduction or the absolute difference between 2.4 and 7.2 deaths per 100,000 person-years?

As to a profit motive, we need not necessarily find villains here. I will be quick to recognize the honest efforts of those who make a living fighting cancer. Physicians need not be greedy to cling to a profitable activity but rather just trying to keep the doors open in this era of diminishing reimbursement for physician services. However, we would be naive to dismiss the notion of a “medical-industrial complex” i.e. a socio-economic force that organically organizes to preserve profit as the primary, if not only, motive.

So we are left with a debate that has powerful advocates on both sides. The debate is not whether mammography has any value. It is rather whether we are willing to limit its use as a screening method when the harm exceeds the benefit. And the harm in this sense is both personal and societal. Each life saved comes at some cost of over-treatment death from treatment including fatal heart disease from radiation, secondary cancers and a chronic state of anxiety amongst middle-class women. By analogy, consider automobile speed limits and death rates in pedestrian-involved accidents. We could lower speed limits until the chance of a pedestrian fatality is practically zero. But at some point livelihoods and lives are lost due to the lack of efficient transportation for work and emergencies.

Hopefully, we will develop screening methods for breast cancer that are more sensitive and more specific. Until then, women and their doctors should share the decision about mammography in individual cases based on an open discussion of both sides of the ongoing controversy. We should avoid bad choices based on fear and hope alone but rather employ new information to gain the most benefit for the risk from mammography.

We are left to wonder what indeed are the best practices? Many of the issues are covered in the three-way debate in the New England Journal — screen at age 40, age 50 or not at all(12).  Dr. Welch notes in his New York Times op-ed article(4): “It has been more than 50 years since the last randomized trial of screening mammography in the United States. Now that treatment is so much better, how much benefit does screening provide? What we need is a clinical trial in the current treatment era.”

We should at least have the courage to test in this country the hypotheses posed by breast cancer screening.

Bio

Dennis Morgan, MD is Assistant Clinical Professor University of Connecticut Health Center, Emeritus Staff Johnson Memorial Hospital and Medical Center Stafford CT and Past President Connecticut Oncology Association as well as Past Medical Director Phoenix Community Cancer Center, Enfield CT

References

1. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. U.S. Preventive Services Task Force. Ann Intern Med. 2009;151(10):716-726.
2. American Cancer Society recommendations for early breast cancer detection in women without breast symptoms. 2014.
3.  Weighing The Value of Mammograms. Monsees B, Rebner M. The Opinion Pages. Letters. New York Times. Jan 2 2014.
4. Breast Cancer Screening: What We Still Don’t Know. Welch HG. The Opinion Pages. New York Times. Dec 29 2013.
5. Quantifying the Benefits and Harms of Screening Mammograph. Welch HG, Passow HJ. JAMA Intern Med. 2014;174(3):448-454
6. Confronting Uncertainty About the Harms and Benefits of Screening Mammography. Bath C. ASCO Post. Feb 15 2014, Volume 5, Issue 3.
7. Screening for breast cancer with mammography (Review). Gøtzsche PC, Jørgensen KJ. The Cochrane Library 2013, Issue 6.
8. Effect of Screening Mammography on Breast-Cancer Mortality in Norway. Klager M et al. N Engl J Med 2010; 363:1203-1210. Sep 23 2010.
9. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. Miller AB. BMJ 2014;348:g366.
10. Annual mammography screening did not reduce long-term breast cancer mortality in women 40 to 59 years of ag. Fletcher SW. ACP Journal Club | Volume 160 • Number 10. May 20 2014
11. Abolishing Mammography Screening Programs? A View from the Swiss Medical Board. Biller-Andorno N, M.D., Ph.D., Jüni P, M.D. N Engl J Med 2014; 370:1965-1967. May 22 2014.
12. Mammography Screening for Breast Cancer. Clinical Decisions. N Engl J Med 2012; 367:e31. Nov 22 2012.

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