Wednesday, November 18, 2009

New breast cancer screening guidelines create confusion and controversy.

The U.S. Preventive Services Task Force (USPSTF) has updated their 2002 recommendation statement on screening for breast cancer in the general population, and the new statement has created a loud controversy among physicians, cancer survivors, women's health advocates and, inevitably, politicians. Making its debut in the midst of a hotly debated healthcare reform bill the timing could hardly be worse.

About the USPSTF:

The USPSTF was established in 1984 to "evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care." The USPSTF is an independent, voluntary body, and "...recommendations made by the USPSTF are independent of the U.S. government, and they should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services."

Here is the outline of the new recommendations:

  • The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
  • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
  • The USPSTF recommends against teaching breast self-examination (BSE).
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.

The primary controversy revolves around the statements against routine screening in women through their 40's, and biennial (rather than annual) screening between 50 to 74 as well as the recommendation against teaching breast self-examination.
The position of the Task Force is that the routine annual screening for breast cancer can cause "...psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results." They also note the overdiagnosis of cancer that would not become clinically apparent during a woman's lifetime, and unnecessary early treatment of breast cancer that may become clinically apparent but would not actually shorten a woman's life. Although "...false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups." They also state that there is adequate evidence that teaching breast self examination (BSE) is associated with harms that are "at least small."

However, The American Cancer Society "...continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider."
Many physicians and women's health advocates are also either confused or seem to be  misinterpreting the recommendations to insinuate that women shouldn't -or won't be allowed to- have a screening at all until they're 40; Dr. John Larrinaga, Medical Director at the Ross Breast Center states: "It doesn't make sense on any level for any person to put their heads in the sand like an ostrich and say we shouldn't be checking ourselves or shouldn't be vigilant about the disease...This is just wrong, this is not scientifically supported." Dr. Ann Marie Shorter, a radiologist with a specialty in breast care says "The statistics are meaningless when it comes to breast cancer deaths if it's your wife, your best friend; these guidelines are a travesty. They don't make sense."
And Rep. Debbie Wasserman Schultz (D-Fla.) "blasted" the report, saying "We can't turn literally 20 years of recommendations ...upside down, and discourage women from becoming familiar with the look and feel of their breasts," and "We can't allow the insurance industry to continue to drive healthcare decisions"

Given the current climate of political diversity on the healthcare bill, the controversy isn't likely to die soon. Meanwhile, breast cancer continues to be the most common form of cancer among women in the US, with about 192,370 new cases of invasive breast cancer expected to be diagnosed in 2009. In our opinion, the best guideline is the old adage: If in doubt, check it out.

Signs and symptoms of breast cancer may include:

  • A breast lump or thickening that feels different from the surrounding tissue
  • Bloody discharge from the nipple
  • Change in the size or shape of a breast
  • Changes to the skin over the breast, such as dimpling
  • Inverted nipple
  • Peeling or flaking of the nipple skin
  • Redness or pitting of the skin over your breast, like the skin of an orange

When to see a doctor:
If you find a lump or other change in your breast — even if a recent mammogram was normal — make an appointment with your doctor.

Tuesday, November 17, 2009

Uninsured trauma patients are much more likely to die --

Uninsured trauma patients are much more likely to die --

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Food Allergies on the Rise in US Children... maybe.

A new cross-sectional survey of data on food allergy among children published online November 16, 2009 in Pediatrics shows that the prevalence of self-reported food allergies in the U.S. increased by 18% from 1997 to 2007, and outpatient visits to medical facilities for treatment of food allergies nearly tripled from 1993 to 2006. The study was the first to make nationally representative trend estimates of food allergy prevalence and healthcare utilization in the U.S. It also took the unusual step of characterizing some food allergy characteristics according to race and ethnicity.The study found that increases in food allergy prevalence were found across gender, age, and race, and findings include:
  • Between 2003 and 2006, children were taken for an estimated average of 317,000 food allergy-related visits per year to emergency rooms and outpatient departments and doctors offices
  • Hospitalizations of children with diagnoses related to food allergy increased from an average of 2,600 discharges per year during the period of 1998 to 2000 to 9,500 discharges per year from 2004 to 2006
  • Black children were twice as likely as white children to test positive for peanut allergies on blood tests and were nearly twice as likely to have detectable signs of milk allergies.
  • Black children were four times as likely as white children to have detectable antibodies for shellfish. While not as likely to have food allergies as black children, Hispanic children were more likely to have food allergies than were white children.
But are allergies really on the rise?

According to previous reports, true food allergies are not as common as most people believe and only affect about 2% of children, although they are more common in younger children. And fortunately, most younger children will outgrow these food allergies by the time they are three years old.
More common than food allergies is food intolerance, which can cause vomiting, diarrhea, spitting up, and skin rashes. An example of such a reaction occurs in children with lactose intolerance, which occurs because of a deficiency of the enzyme lactase, which normally breaks down the sugar lactose. Children without this enzyme or who have a decreased amount of the enzyme, develop symptoms after drinking lactose containing food products, such as cow's milk. However, because this reaction does not involve the immune system, it is not a real food allergy.

One theory of interest suggests the recent rise could be related to a phenomenon known as the hygiene hypothesis, according to the Food Allergy and Anaphylaxis Network. "Because children in our culture are exposed to fewer germs than their bodies are used to dealing with, the immune system is deprived of the full-time germ-fighting job they have to do, and [immune systems] misidentify food as harmful" she says.
After identifying food as harmful, the body reacts by trying to fight the food—resulting in an allergic reaction with symptoms ranging from relatively benign ones, like hives, rashes and tingling in the mouth, to terrifying ones, like swelling in the throat, difficulty breathing and loss of consciousness.

However the study notes that "Several national health surveys indicate that food allergy prevalence and/or awareness has increased among US children in recent years."
And researcher Amy M. Branum, MSPH, of National Center for Health Statistics at the CDC adds "Reported food allergy is increasing among children of all ages, among boys and girls, and among children of different races/ethnicities, however, it cannot be determined how much of the increases in estimates are truly attributable to increases in clinical disease and how much are attributable to increased awareness by physicians, other health care providers, and parents."

So the reality is that while there may be some actual increase in allergic reactions to our children's food, the study suggests more of an increase in the general awareness and reporting of food allergies.

About Food Allergies:

Some food allergies result in immediate, severe and even life-threatening symptoms (such as severe peanut allergy), whereas others cause symptoms which may take longer to develop (for example, gluten allergy, also known as coeliac disease). They can result in immediate, severe and even life-threatening symptoms (such as severe peanut allergy), whereas others cause symptoms which may take longer to develop (for example, gluten allergy, also known as coeliac disease).
The diagnosis of a food allergy isn't always straightforward. Many food allergy symptoms can also be caused by a number of other conditions and it may take some time before the problem food is identified and your doctor can confirm that you have an allergy.

The only treatment for food allergy is not to eat the problem food. A registered dietitian can help you identify and remove a problem food from your diet and replace it with alternatives, to make sure you don't miss out on essential nutrients. Your dietitian can also explain what you need to look for on food labels and when eating out. Symptoms of mild food allergies, such as a rash or runny nose, may be treated with antihistamines. However, it's important that you only take medicines for your allergy on the advice of your doctor. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.