I've written before about how bad human beings are at assessing risk (see http://www.novamedgroup.com/measles-outbreak) and lately several conversations with patients have highlighted for me just how important it is for family physicians to engage their patients in a dialogue about risk.
I keep hearing from my patients who refuse mammograms that the reason they are not getting routine  breast cancer screening is that they are concerned about the effects of radiation. They are especially worried about the cumulative effects of the radiation on their overall cancer risk.
Radiation is certainly something we should all be thinking about and aware of when we order imaging tests but I would like to put the concern over mammograms into perspective.
A single mammogram gives about a 0.8 mSv dose of radiation which raises cancer risk by 0.004%.
If a 50 year old woman follows the USPSTF guidelines and gets a mammogram every other year until she is 75, her additional overall cancer risk will be 0.05%. The average woman has a 12% chance of getting breast cancer.
On the other hand, I get asked all the time if I can order whole body CT scans to screen for disease in healthy patients. The dose of radiation you get from a whole body CT scan? 12 mSv! If you got this yearly as a sort of "virtual checkup" like some centers are advertising, there is a 1 in 50 chance you will die of a radiation related cancer. (Not to mention all of the things that would be found that I would have to chase up and in the end would likely not be anything dangerous. In my opinion, a whole body CT scan in an asymptomatic patient is like opening up Pandora's box).
To sum up, there is definitely a time and place to worry about how much radiation you are getting, but routine mammography is not it and no one should avoid a potentially life saving test over a fear of radiation.
For CT scans and other high dose imaging tests it is a good idea to keep track of your own radiation risk.
http://www.xrayrisk.com is a fantastic site that lets you put in all your tests and it will calculate your cumulative risk.

Breast Cancer Awareness Month and BRCA mutations

In honor of breast cancer awareness month, I thought I'd write about 2 highly pertinent topics: BRCA testing and automated whole breast ultrasound.
You may be familiar with BRCA gene mutations. Angelina Jolie famously had a preventive double mastectomy in 2013 after she was found to be a carrier for one of these mutations. There are 2 known genes, BRCA-1 and BRCA-2. Mutations in these genes significantly increase a woman's risk of both breast and ovarian cancer.
BRCA has been back in the news lately thanks to a study from Mary-Claire King, the researcher who first identified BRCA-1.
The study found that even women who have no family history of breast cancer can carry a BRCA gene mutation and that it increases their risk by the same amount as women who do have a family history.
Here's the problem: the study was done in a particular ethnic group known as Ashkenazi Jews who have a much higher rate of BRCA gene mutations than the general population.
Dr. King has called for universal screening for ALL women regardless of ethnicity  based on these findings even though the prevalence in the general population is much lower. Most non-Ashkenazi Jewish women with breast cancer do not have a BRCA mutation. Screening everyone may lead to an increased number of false positives as well as increased false sense of security. I worry that women will get tested, get a negative result and then neglect routine breast cancer screening as a result. After all, 1 in 8 women will get breast cancer in their lifetime and most of these do not carry a BRCA mutation. Screening may also lead to women having unnecessary radical surgeries like mastectomies and oophorectomies. On the plus side, some women may be more proactive about their screening and may get additional tests like breast MRI or may take a medication to reduce their risk, however we already have a well established risk predictor model called the Gail Breast Cancer Risk Model as well as criteria for who should get BRCA testing. Instead of universally testing all women for a mutation that they are unlikely to have, I would like to see primary care doctors using these risk models and talking to women about their personal risk and what the screening options are.
Which leads me to a new screening tool for breast cancer. Some of you may have noticed that you now get a notification from you breast radiologist that you have "dense breasts". Your breasts are considered dense if you have a lot of fibrous or glandular tissue but not much fat.Dense tissue appears white on a mammogram. Lumps, both benign and cancerous also appear white so dense breasts make it more difficult for doctors to spot cancer on mammograms.
A JAMA study published in 2008 shows that when adding ultrasound to mammographic screening, researchers found an additional 1.1 to 7.2 cancers per 1,000 in women with dense breasts.
So if you have a history of dense breasts, ask your doctor if additional breast ultrasound would be right for you.

School Lunches

I was somewhat amused that my daughter's new school put a comparison chart on their website to show that school lunches are healthier than packed lunches. The packed lunch they chose?

Really people??? Almost anything is better than Lunchables! This particular one includes breaded chicken poppers, American cheese, pretzel sticks, fruit juice and chocolate kisses. I think we can all agree that this is not a healthy meal given that there is not a fruit (no, Capri fruit punch does not count) or vegetable in sight and it contains a whopping 540 mg of sodium and 6 grams of saturated fat. You are not setting the bar very high if this is what you are comparing yourselves too. A lot of school districts have worked very hard and have made vast improvements in their menus, but  there is no escaping the fact that school lunches are still too high in sodium, fat and unhealthy carbs. This weeks school menu did offer salads and fruit, but the entrees consisted of pizza, hamburgers, and chicken nuggets. 

The fact is, with a little preparation, you can absolutely make your child a healthy lunch. Your options are not limited to school lunches and Lunchables.

While I was boiling some potatoes for dinner yesterday I popped in a couple of eggs and my daughter had hard boiled eggs and cheese for lunch today with carrot sticks, hummus and sliced strawberries. Other lunches this week have included veggie chips, peanut butter and apple slices, raspberries and spinach littles.

When the weather gets cooler, I plan on sending a thermos with soup or dinner leftovers.

There are literally tons of great lunch ideas online. You don't have to make them Pinterest-worthy, just tasty and healthy. And yes it's ok to slip in a little treat if the rest of the lunch is well-balanced. My daughter has declared Fridays treat day so tomorrow she'll get some organic Oreo cookies for snack.

I do still plan on working towards healthier school lunches as part of the overall goal of family medicine to improve the health of all children. There are kids whose parents cannot to make a lunch of any kind and rely on subsidized lunches. The Healthy-Hunger Free Kids Act of 2010, which addresses some of the issues with school lunches is getting a lot of push back from food industry groups and some members of Congress. I absolutely do not want to see the gains that have been made like getting rid of soda  be pushed back by politicians and the CEOs of Kraft and Nabisco. If you care about our national child obesity crisis, please consider getting involved too. You can find more information at:

http://www.pcrm.org/health/healthy-school-lunches/

Why you don't need a pap smear every year

I find it funny that when new breast cancer screening guidelines were introduced a couple of years ago there was an uproar. It was on the nightly news, countless articles were published, leading breast cancer authorities were interviewed, patients gave their testimonies and so on. But when the pap smear guidelines were changed around the same time....nothing. You could have heard the crickets chirping. Perhaps it's because no one likes to get a pap test, but I have not heard much complaining about the changes! A lot of women are still confused, however, about what the new guidelines mean for them. So, here are the most important points. 1. Pap smears are no longer recommended for anyone under the age of 21. 2. Women between 21 and 30 should get a pap smear every 3 years. 3. Women between 30 and 65 should get a pap smear and HPV testing every 5 years (a pap smear alone every 3 years is also acceptable). 4. Women over 65 with no history of cervical cancer or serious precancerous lesions should stop getting pap smears. Previously, all women over 18 or within 3 years of the onset of sexual activity were getting pap smears every year. So why the changes? Wouldn't we want to screen for cervical cancer as much as possible? Isn't screening a good thing? To understand the rationale behind the changes, you have to understand the natural history of cervical cancer. The cervix is a cylinder shaped neck of tissue connecting the uterus to the vagina. It dilates slightly to allow the passage of menstrual blood and a lot to allow passage of a baby! There is an area on the cervix where the cells transform from the cells that line the vagina to those that line the inside of the cervix. This is called the transformation zone and it is susceptible to infection by a sexually transmitted disease called Human Papilloma Virus (HPV). HPV causes cellular changes and over time these can accumulate and lead to cancer. Young women have larger transformation zones and are more vulnerable to HPV and therefore to these changes. But younger women are also more likely to clear the virus and repair those changes. When we were screening young women yearly, many of them who were found to have precancerous lesions received unncessary treatment for them because they would never have become cancer. Unnecessary treatment can lead to pain and bleeding from procedures, anxiety and pregnancy complications. Women who have had a LEEP (a procedure that cuts out an abnormal area of the cervix) have higher rates of preterm birth, low birth weight babies and premature ruputure of their membranes. Women over 30 are less likely to clear HPV infections and have higher rates of progression to serious precancerous and cancerous lesions which is why HPV testing is recommended in this age group. The longer screening intervals makes sense when you think about the fact that it usually takes several years to accumulate enough changes in the cervical cells to become cancer. It is exceedingly rare to go from a normal pap smear to cervical cancer in 1 year. Screening too frequently can also lead to false positive results. So embrace the fact that this is a test most of us can get by with having less often. Oh and by the way, ladies, we owe a debt of eternal gratitude to Dr. Papanicolaou's wife Mary who let him take the first cervical smears that allowed him to develop what we now call the pap test. Prior to its introduction in the late 1940s, cervical cancer was the #1 killer of women. Thank you Mary!

Mammograms are going 3D

You thought that it was only blockbuster movies going 3D! Well, screening mammograms are now available in 3D. Instead of a traditional flat image, 3D mammography, otherwise known as tomosynthesis, provides multiple digital images of the breast in slices which are then reconstructed by a computer to generate a 3D image.
Until now, there has been little evidence that this new technology offers any advantage to regular film or 2D digital mammography.
We now have a study recently published in JAMA* that shows an increase in cancer detection rate, particularly for invasive breast cancers. Regular 2 D mammograms required 815 women to be screened to find 1 invasive breast cancer and 3D mammograms required 707 women to be screened. It also showed a decreased recall rate for additional images, 107 women versus 91.
The study was not done over a long enough period to determine if 3D mammograms actually improve outcomes for patients, i.e. less breast cancer deaths.
There are some downsides, chiefly a higher dose of radiation for women with large breasts and the possibility of over detection. When a screening test gets too good, it can pick up things that would never have actually become a problem. This can lead to unnecessary treatment and a whole lot of anxiety. Lastly, 3D mammography is more costly and some insurance companies are not covering it.
So who should get this new kind of screening? Most women will be fine with regular 2D, but for women who have dense breasts, a higher than average risk of breast cancer, or have had a lot of recalls in the past, 3D mammography may be better.

*JAMA,June 25, 2014, Vol 311, No. 24 

The Truth About Whole Grains

My husband absolutely detests whole wheat anything. He thinks it tastes like cardboard and has steadfastly refused to jump on the whole wheat bandwagon. Instead he just eats smaller portions of white bread and pasta less frequently. All my cajoling about whole wheat being healthier fell on deaf ears. Turns out that my non-physician husband with absolutely no formal nutrition training was absolutely right! Processed whole wheat is actually no better for you. So much for telling my patients to just eat the "brown" foods! When you take whole wheat, or any grain for that matter, and grind it into a meal or flour to make bread or pasta, you are increasing the surface area available for your digestive enzymes to break the carbohydrates down into sugars. Whole wheat bread has the same glycemic index (how much a food causes your blood sugar to rise) as white bread! Unfortunately, the Whole Grains Council considers a food to be a whole grain if it still contains the 3 components of a grain (bran, germ and endosperm)after processing. I found the Whole Grain Stamp on a package of Snyder's Multigrain Cheese Puffs whose only "grains" were corn meal and rice flour. Yet the label proclaimed "20 grams of whole grain per serving"! It drives me crazy that we are all being tricked into thinking we are making a healthier choice, when in reality we are being sold products that are no better for us than regular old Cheetos and Wonderbread. So, what can we do? Choose actual whole grains! Instead of instant oatmeal which is basically pulverized oats and sugar, make up a batch of slow cooked rolled oats. Brown rice, quinoa, millet, bulgur and spelt wheat can all be made into delicious side dishes or can form the basis of a whole meal. When it comes to bread and pasta,look for brands like Ezekiel or Mestemacher which use whole grains and sprouted grains instead of flour. Liana Krissoff's excellent "Whole Grains for a New Generation" cookbook offers loads of delicious ideas. And be like my husband, enjoy your white, refined flour products in moderation.

The Problem with Diet Books

I was on Amazon recently checking out diet books and the number was staggering. Atkins, South Beach, Paleo, Wheat Belly...the list goes on. They all seem to have 2 things in common. They all promise weight loss and to achieve this weight loss you must generally remove an entire food group from your diet (usually grains, although I did find one called The Carb Lovers Diet!). I have several problems with these diet books. Firstly, the word diet itself has so many negative connotations. Diets to me imply restriction and a certain level of misery! I would personally much rather focus on the foods I should be eating than the ones that I shouldn't. I recently completed a fitness challenge at work and I loved it that the weekly assignments were things like "eat 3 vegetables a day" and "eat lean protein with every meal" instead of "don't eat candy". I found that whenI was making healthy choices I was naturally making less unhealthy ones, but I felt a lot better about it! Secondly, diets are not sustainable. In my experience, people tend to follow a diet for a certain amount of time and when they have achieved their desired weight loss they slip back into old habits. I prefer to think in terms of lifestyle change instead of dieting because change implies permanancy and sustainability. Thirdly, many normal weight people also need help making healthier food choices and since most diet books emphasize weight loss, these books often seem inaccessible. Lastly and most importantly, most of these diet books are not based on good science. The current trend is to eliminate gluten, a protein contained mainly in wheat. There are few rigorous scientific studies to suggest that this is a healthy lifestyle change unless you have a medical condition like Celiac disease. I have seen patients come back after going gluten free unhealthier than they were before because a lot of gluten free products are based on corn and white rice which have a high glycemic index (i.e. raise the blood sugar). Following food fads can have dangerous consequences. 20 years ago fat was the boogie man and everything was marketed as low-fat. Our rates of diabetes skyrocketed because food manufacturers simply replaced fat with sugar. Instead of promoting the latest trendy diet, I would like to introduce you instead to the Mediterranean style of eating. It has been the most rigorously studied "diet" since the 1940s. In fact, just this year alone there have been 4 major medical studies showing its health benefits. The Mediterranean food pyramid is rich in whole grains, fruits and vegetables as well as fish along with dairy like greek yogurt and ricotta and mozarella cheeses. Nuts, olive and red wine feature prominently and red meat and sweets are eaten sparingly but are not completely forbidden. It is a nutritional approach that promotes moderation and emphasis is placed on physical activity and enjoying food with others. This style of eating can be modified to accomodate cultural food prefences and it works well for multiple chronic conditions like diabetes, high cholesterol, high blood pressure, etc. Oldways, a foundation promoting traditional diets has a wonderful section on Mediterranan eating. http://oldwayspt.org/resources/heritage-pyramids/mediterranean-pyramid/overview I would also recommend Dr. Ornish's wonderful book "The Spectrum" which addresses lifestyle changes for cardiovascular disease prevention and treatment and includes a section on nutrition, which he bases on the Mediterranean plan. As Michael Pollan said, the best way to eat can be summed up as "eat real food, but not too much and mostly plants"!