February 2012-Resolutions for 2012 Once a year on New Year’s Eve cultures all across the globe celebrate the ending of one year and the beginning of another. This is done with much pomp and fanfare to extirpate the past demons and to placate the future ones to ensure prosperity, health, love, etc. Whether the ritual is performed by screaming, fireworks, dragons, bells, banging pots or throwing garbage out of windows, the same result is sought. The morning after, in the clear light of day and sobriety, resolutions are made: some in remorse for a bad previous year and others in hopes of “turning things around”. Without critiquing the usual nonsensical resolutions that are never kept, as a physician for women, I would like to offer some resolutions that I believe will have a positive impact on all people, women especially. Young women should take charge of their reproductive health and seek appropriate contraception when not immediately interested in child bearing and, if considering a child in the near future, maintain a lifestyle that is healthy to a developing embryo and fetus. Daily vitamins that include folic acid, no alcohol or drugs and healthy diet not only improve the chance of conceiving but also reduce certain birth defects. Many women do not receive regular health care and especially are reluctant to have pap smears done. It would be wise to put that fear aside and resolve to see a primary care provider AND a gynecologist. Lab tests can help detect previously nonsymptomatic disease and a careful physical exam will hopefully be negative but possibly detect lumps, bumps, tumors malignant or benign. The Pap smear detects early cervical changes that might lead to cervical cancer and, if early, can be treated easily in office. These office visits will also, when appropriate, lead to screening colonoscopy, bone density, mammogram, cholesterol screening, and chest x-rays, ekg’s and vaccinations for flu and pneumonia. Most of these tests are covered by third party payors and when and if positive need not have a grim prognosis. Early detection and treatment is paramount so indeed RESOLVE to get this done. This past year there was a push to educate women about the risk of heart disease. While the “push” might be over, the risk still exists. The number one killer of men and women in the United States is heart disease. Women do not have quite the same symptoms as men. They are usually more subtle and might not be anything more than feeling a little warm and a slight tingling in the arm or chin. Women with these symptoms should RESOLVE to be seen and to get a stress echocardiogram and evaluation for heart disease.
So, everyone swears off alcohol after the debauchery and excesses of the holiday season. This is laudable but usually not long lasting and a more prudent approach would be to RESOLVE to change lifestyle. I have written here exhaustively about obesity and the attendant risks. A resolution to lose weight would include avoidance of carbohydrates; limit or eliminate products with high fructose corn syrup; not eating “fast food”, portion control, and simply “not eating anything white”—that includes pasta, pizza, bagels, donuts, potatoes, etc. A life style change must include a resolution to stop smoking. No one would even debate the cause and effect. There is no early diagnosis for lung cancer and the death is a miserable one characterized by slow strangulation. There are a few prescription products to help cure the addition and nicotine patches to slowly wean off cigarettes. These all fail without the WILL to stop. Unless the habit of smoking is stopped the addiction to nicotine cannot be helped. All physicians are trained in therapy for this, New York State has a hot line, counselors, hypnotists and acupuncturists abound and will be successful if the patient truly wants to quit. A discussion about resolutions would not be complete without some advice concerning medications and recreational drugs. As the economy has worsened and joblessness has increased, drug use has gone up through the roof. Recreational drugs such as marijuana, ecstasy, are showing up in blood tests of newborns and odd behaviors in patients usually point to drug use. A very large problem now is the use of prescription narcotics for a wide range of maladies, usually chronic back pain. Sadly, these patients are rendered addicted by these “chronic” conditions and the impact on the rest of their health care is tremendous. Anesthesia is more difficult, pain control from surgery is difficult, blood loss is increased, etc. A wise resolution would be to have all medications, especially narcotics reviewed by a physician periodically with the goal of wellness through appropriate treatment and not just masking pain with addictive and expensive drugs. This list of resolutions can be just the beginning of empowerment. I would also add that a resolution to improve relationship with spouses, partners and family members can make for a happier life. The New Year has arrived. Get going! Make it happen and next year you will be cheering about how great the year was and not just hoping for a better one.
January 2012-Breast Cancer Risks
Recently there has been much in the media about new research delineating the risks of getting breast cancer. I cannot overly emphasize the importance of women and men knowing these risks since reducing the incidence of the disease are important and, early diagnosis in all persons, especially those at high risk, markedly increases survival. While it would seem that we hear so much about breast cancer now it is tempting to think of it as a disease of modern times. It is true that we are living longer and as great inroads are being made to increase survival from trauma, childbirth, heart disease and diabetes, old age becomes a fertile ground for cancer because aging cells lose their ability to grow normally and to ward off toxins and insults that will be discussed here. Medical history is replete with annotations of breast cancer as long ago as 2500 b.c. when Queen Atossa of Egypt was in so much pain from breast cancer that she had a slave cut her breast off. The record indicates that she was in her late thirties. The Dark and Middle Ages record breast cancer and very grisly attempts at removal that did not cure the disease and most probably killed the patient from blood loss and pain. The discovery of ether by a dentist in the late 1800’s ushered in the era of modern surgery under anesthesia. Halstead, the “father” of breast surgery was of the belief that the more radical the surgery the more likely the cure. He coined the term “radical mastectomy” in which the breast, chest muscles, lymph nodes of the armpit and sometimes even the clavicle and part of the shoulder were removed. Years later under strict scientific scrutiny there was no evidence that such a radical disfiguring procedure resulted in greater longevity for the cancer patient. Radiation therapy was discovered when cells exposed to huge doses of x-rays stopped growing in the lab. Chemotherapy had a complicated birth after it was discovered that soldiers exposed to nitrogen mustard gas in world war two had bone marrow suppression if they survived. After many studies and bold research the two modalities were combined so that today most treatment (in patients in which the tumor at the time of diagnosis has not spread beyond the chest) involved lumpectomy, radiation and various chemotherapeutic drugs. New research into gene treatment has resulted in adjuvant therapy in which types of antibodies are used to correct the genes that are so confused that they produce cancer. Survival rates are markedly improved and disfigurement and disability from surgery are rare.
But what of the risks? Forty years ago the standard teaching was that if a woman lived to 72 her risk was one in thirteen of getting breast cancer. Now it is one in eight. Once the entire human genome was mapped, there was the discovery of the BRACA 1 and BRACA 2 gene which if detected by a special test would predict an 80% chance of breast and/or ovarian cancer in women and prostate cancer in men. This is found in people of Eastern European origin especially Ashkenazi Jews of that region. However, it must be understood that only one in ten women who get breast cancer have that gene so that there must be other risk factors. Obesity (defined as a body mass index of greater than 30) markedly increases the risk. It is not completely clear if this is from ingestion of fat laden foods (cultures such as Japan with low fat meals have low rates of breast cancer) or that of the hormone estrogen. Estrogen is the female hormone that is produced in the ovaries and in body fat. Possibly, more fat, more estrogen, more cancer. Woman frequently ask me for plant based estrogen products in the thought that if it is “natural” it must be less risky. There is no evidence to support that thought as plants contain isoflavones that in high doses pose the same risk. The known carcinogens in tobacco smoke increase the risk of breast cancer. Alcohol consumption is now identified as a risk with as little as 3-4 drinks/week being worrisome. The chemicals found in plastic bottles are now becoming known as risk factors and then there are environmental toxins in the air, water, and soil that are still under investigation. So, knowing these risks should alert people to avoid lifestyles that embody these risks. Be active, lose weight, don’t smoke, drink alcohol in moderation, and eat healthy. If at least one sibling and mother or aunt have had breast cancer it worth inquiring about being tested for the BRACA gene although a fight with the insurance company is a given. Women should also be comfortable and frequent with their own breast exam and, if not, be taught by their health care provider. There is no doubt that annual mammography after age 40 with digital interpretation allows for earlier diagnosis and treatment. Be aware of the danger signs: any breast lump, nipple discharge, especially if bloody, pain, or skin changes over the breast warrant exam. Knowledge is empowerment. As mentioned above, treatment though arduous need not be disfiguring and that there are many breast cancer survivors is an attestation to the joy of being with their loved ones and living long and productive lives. December 2011-“Too Posh to Push?” A couple of weeks ago I came across an MSNBC article while perusing the internet entitled as above “too posh to push” about elective cesarean section (that means, no labor –just a scheduled operation). I thought this a clever phrase but I did not coin it. It seems that many celebrities, as they approach their due date for delivery, persuade their obstetrician to perform an elective cesarean before they go into labor. I am addressing this issue now because in my capacity as ACOG Vice Chair for New York I participate in many committees, some of which go all the way up to the New York State Department of Health , that are examining this very issue. Faced with huge budget deficits, unfunded mandates, and the Patient Protection and Affordable Care Act (“Obama care”) New York is compelled to trim costs to the health care system. Governor Cuomo has convened a Medicaid Redesign Team as he is well aware that at current rates of eligibility and cost, the program is not sustainable. One aspect of cost cutting involves obstetrics. Right now the Department of Health has stated that they will not reimburse doctors or hospitals for “non indicated” inductions of labor before 39 weeks (40 weeks is full term) AND will not pay for non indicated c-sections. Contrary to what the public believes, obstetricians who accept Medicaid do not receive higher reimbursement for an operative delivery. Therefore, they can make a decision to operate or perform a vaginal delivery on the merits of the case alone. A case could be made for higher reimbursement given that a c-section has more risk, requires a higher grade of malpractice insurance, takes more time, involves more charting and more rounds and requires a post operative exam. Hospitals have higher costs in operating room equipment and personnel, anesthesia, assistants and more days spent as an in patient. While it would seem reasonable that the health department uses the term “non-indicated”, they have not comprised a list of what “indicated” is! ACOG has been asked to be at the table and has generated a list of when it is possible and even desirable to be delivered before 39 weeks. In March 2010, I wrote an article on the reasons for c-section and will briefly reiterate here reasons for either induction or c-section: maternal reasons to include infection of lungs or genital tract, viral illnesses that compromise the fetus, heart disease of the mother, preeclampsia or eclampsia (both life threatening conditions of pregnancy secondary to high blood pressure and kidney and blood abnormalities); fetal reasons that would include multiple gestation (twins etc.), breach or other malpresentations, bleeding, abnormal heart rate tracings, intrauterine growth retardation, twin twin transfusion, etc. etc. This list is long but not exclusive of other conditions. There are social reasons to be considered also: living far from the hospital, history of rapid labors, impending Oswego winter “white outs”. It must absolutely be remembered that while c-section is now very common it is a major operation with a five fold risk to the mom over vaginal delivery. These risks would include fatal anesthesia reactions, pulmonary embolism, pneumonia, wound and uterine infections, profound bleeding, organ injury, fetal injury and long term possibility of pain from scarring, hernias, etc. Given these possibilities why would any woman elect to forego labor and have an elective c-section as is common among celebrities and in countries like Brazil? Are these woman indeed “too posh to push”? A certain amount of elitism enters into the equation with the desire to control the entire birth process “risk be damned”. Many of these women fear labor and its attendant discomfort but are not realistic in understanding postoperative c-section pain that can lead to six weeks of disability. Also, some find the whole process of a vaginal birth to be “yucky” what with panting, grunting, pushing, bleeding, stitches, etc. And believe it or not there are those who wish to control the date of birth because it is catchy (say 11/11/11) or is the same day that Uncle Harry was born. The reality is that delivery before 39 week is absolutely proscribed by my profession unless indications, like those above, are present. There continues to be fetal neurologic development in the last week of pregnancy. Emulating a celebrity to have an elective induction or c-section without labor, especially before 39 weeks can be a terrible mistake. These issues are best discussed with an obstetrical provider and not gleaned from a tabloid newspaper. The anatomy of a female and the physiology of human reproduction and pregnancy make clear that a vaginal delivery is the norm. Only when specific indications are present should an early preterm induction be done or a c-section performed. It is also worth noting that starlets who deliver at home have the financial resources to enable them to convert a room in their house to a fully functional hospital labor room with all contingencies for emergency readily available. Good, early, and professional prenatal care makes for healthy infants and children that go on to be happy productive members of society. |
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