Swine flu, embryonic stem cells are high on these (early) top 10 lists

The reflections on 2009 have begun.

-- This week, the Harvard Health Letter offers up its top 10 health stories of the year. Leading the list is the H1N1 influenza pandemic. Second is healthcare reform.

-- The Scientist touts its top 10 innovations of the year. Leading that list is researchers' newfound ability to convert cells to an embryonic-like state using only proteins. Second is a new machine that could be used to identify viruses or bacteria during an outbreak.

-- And AOL hands over its top 10 health-conditions searches. No link, so we'll give you the whole list: Tops is ... yep, swine flu. Followed by lupus, diabetes, pregnancy, depression, herpes, fibromyalgia, autism, HPV and breast cancer.

By my calendar, we still have about a twelfth of the year to go, but apparently no one expects much of poor December.

-- Tami Dennis

Photo: A woman wears a mask in the Beijing subway. In China, as in the rest of the world, swine flu has taken a toll. Credit: Peter Parks / AFP/Getty Images

And now for Barbara Ehrenreich's take on the mammogram furor

Author Barbara Ehrenreich begins her column on today's Opinion page:

"Has feminism been replaced by the pink-ribbon breast cancer cult? When the House passed the Stupak amendment, which would take away abortion rights from women who get any government help purchasing insurance, the female response ranged from muted to inaudible.

Soon after, when the U.S. Preventive Services Task Force recommended that regular screening mammography not start until age 50, all hell broke loose."

Read more from Ehrenreich.

Here's the original news article: Mammogram guidelines spark heated debate

And a followup: Cancer screening: What could it hurt? A lot, actually

-- Tami Dennis

Photo: Barbara Ehrenreich. Credit: Sigrid Estrada / Metropolitan Books

Routine cancer screening can be too much of a good thing

Doctors and patients are still grappling with the notion that when it comes to cancer screening, more isn't always better. A reader from West Springfield, Mass., offered to share this cautionary tale of what happened to her when a routine test indicated she might be at risk for gallbladder cancer:

In August, I went through a completely unnecessary surgery that has left me with problems that I did not have prior to the surgery. About six years ago, a polyp was found on my gallbladder. I worried for about two months that I was going to die, until I finally got in to see a gastroenterologist. He told me, "We don't do anything about those. We would find those if we scanned people at random on the street. There has to be some limit." For a second or two, I wondered if he was making a cost-benefit analysis that might hurt me if this particular polyp turned out to be the rare one that was a problem. But for the most part, I stopped worrying about it, and did not think about that polyp again for several years.

Unfortunately, that doctor retired, and my new doctor was much more "conscientious." He told me we had to screen the polyp every six months to make sure it was not growing. That went on for a couple of years until one test said that the polyp had grown (although that made little sense because they told me it had "grown" to the same size that it was six years ago when it was first discovered). What followed were many agonizing months in which I tried to decide if I should have my gallbladder removed. I sought second opinions and read research concerning gallbladder cancer. It is extremely rare, but very deadly if not caught soon enough. I was frightened by "horror stories" from others who'd had the surgery and suffered adverse effects. I also heard from many people who said they felt much better after the surgery. The doctors, of course, minimized any negatives to the surgery. The only complication they informed me of was the possibility of having diarrhea for the rest of my life. But don't worry, they said, there's a pill for that.

In the end, I had the surgery done, and I deeply regret it. The surgeon found a cholesterol polyp that I could have lived with for the rest of my life. First of all, I was completely traumatized by the surgery. I was horrified that an organ had been removed from my body and sickened by the thought that someone had opened up my body and taken something out. This was an unexpected, emotional reaction that overwhelmed me for several days following the surgery and left me crying almost constantly. Of course, to the doctors, surgery is routine, but I had never had surgery before.

Now, three months later I am suffering from some problems I did not have before the surgery. A number of people, including the surgeon, have told me that I should simply be grateful that I did not have cancer. They tell me that surgery was the right decision because it is better to have the gall bladder removed than to take a chance of having a malignant tumor. I cannot agree with this logic. A certain percentage of the population -- millions of people -- have polyps on their gallbladder. Six thousand people die from gallbladder cancer each year. We simply cannot remove millions of gallbladders to prevent 6000 cases of cancer. Fortunately, most of the people who have polyps do not know about them, because their abdomens have never been scanned. Unfortunately, mine was, setting off a chain reaction of events that eventually led to a completely unnecessary surgery.

Why was my abdomen scanned six years ago? My primary care doctor was performing a routine physical, pressing down all over my belly and abdomen asking me if I felt any tenderness. I did not know how to answer. My abdomen is lean (and extremely ticklish). I was not sure how to distinguish between “tenderness” and the normal pressure anyone would feel during such an exam. During one of her many presses, I answered yes, that I felt some tenderness. She immediately ordered a test. I thought about canceling, as I was in no real pain, but I didn’t. I went ahead with the scan, and that is how the polyp was first discovered.

-- Karen Kaplan

Photo: Doctors performing laproscopic gallbladder surgery. Credit: Allen J. Schaben/Los Angeles Times

This pink-gloved hospital is rockin'

Just when it appears that the country has maxed out on ways to promote breast cancer awareness and the ubiquitous pink-ribbon campaign, the staff of Providence Saint Vincent Medical Center in Portland, Ore., has outdone everyone. The staff -- I'm talking everyone -- donned pink medical gloves to star in their own YouTube video to promote breast cancer awareness.

"Our employees put together this video to generate breast cancer awareness throughout our hospital system. We had a ton of fun putting this together and hope it inspires others to join in the cause," says a statement from the hospitals.  

Called the "Pink Glove Dance," housekeeping staff, cooks, cashiers, office workers, nurses, doctors, aides, technicians and administrators strut their stuff wearing pink gloves. The pink gloves are sold to raise funds for breast cancer, and the Providence folks do the gloves proud. Featuring solo dances (the mop guy has serious moves) as well as a choreographed group dance (watch your back, Rockettes), the video is climbing the YouTube charts. My personal favorites are the operating-room team, who benefit from good lighting, and the cafeteria workers, who have nice props. But check it out for yourself.

And you thought hospitals were grim!

-- Shari Roan

Mammography may increase cancer risk for some women

Women who have a known genetic or hereditary risk of developing breast cancer are advised to get regular mammograms, often beginning as early as age 20. But the benefits of such vigilance may be offset by the harm from receiving so much radiation, according to research presented today at the annual meeting of the Radiological Society of North America.

Researchers conducted a review of previous studies to look at whether low-dose radiation from mammography affects breast cancer risk among high-risk women. They found six studies that addressed this question and, using data from those studies, they were able to estimate the odds for radiation-induced breast cancer risk. They found that, among all high-risk women, the average increased risk of breast cancer due to low-dose radiation was 1.5 times greater compared with high-risk women not exposed to radiation. High-risk women exposed before age 20 or who those who had five or more exposures were 2.5 times more likely to develop breast cancer than high-risk women not exposed to low-dose radiation. Radiation exposure is thought to be more dangerous in younger women than older women because of higher rates of cell growth among younger women

Women at high risk for breast cancer are often urged to undergo both mammography and breast MRI each year from the ages of 25 to 65, said the lead author of the study, Dr. Marijke C. Jansen-van der Weide, an epidemiologist with the Department of Epidemiology and Radiology at University Medical Center Groningen in the Netherlands. High-risk women and their doctors may want to consider alternative screening methods, such as ultrasound and MRI, she said.

"It's very important for high-risk women to be screened," she said in a telephone interview. "But for young high-risk women it's important to weigh the benefits and risks of mammography screening with their doctors because there are alternative screenings strategies like MRIs."

MRIs may be underutilized for these women. There are drawbacks to these methods, however. MRI's have higher rates of false positives, are more expensive and more time-consuming.
 
The study included small numbers of women, Jansen-van der Weide noted. Larger studies should be conducted to better understand the radiation risks conferred by mammography.

-- Shari Roan

Photo credit: Beebe / Custom Medical Stock Photo

Rodent of the Week: Implanted vaccine attacks cancer

Several cancer vaccines that are delivered via injections or intravenous lines are in development. Another approach to a vaccine, however, is to implant a small disk containing cancer-fighting substances under the skin, according to researchers from Harvard University and the Dana-Farber Cancer Institute.

The scientists showed they could implant a plastic disk containing tumor-specific antigens under the skin of mice. The substances on the disk caused the immune system to mount an attack on cancer cells and eliminated melanoma tumors. The study was published this week in the journal Science Translational Medicine.

"Inserted anywhere under the skin - much like the implantable contraceptives that can be placed in a woman's arm - the implants activate an immune response that destroys tumor cells," the lead author of the study, David J. Mooney. a professor of bioengineering at Harvard, said in a news release.

The implant approach may be less cumbersome and and more effective than other types of cancer vaccines. Most cancer vaccines remove immune cells from the body, reprogram them to attack cancer and return them to the body. But the re-injected cells can die before completing their task. The implant harnesses several types of cells that direct potent immune responses while protecting healthy tissue.

-- Shari Roan

Photo credit: Advanced Cell Technology Inc.

Healthcare must be rationed, including mammograms, doctor says

Yet another doctor has come out with a critique of the new breast cancer screening guidelines released last week by the U.S. Preventive Services Task Force.

Writing in the New England Journal of Medicine, Dr. Robert Truog of Harvard Medical School says routine screening for women between age 39 and 49 has cut the risk of death from breast cancer by 15%: “Clearly, screening mammography does offer an identifiable survival benefit to women in this age group.”

But he doesn’t necessarily oppose the task force’s final result. Though the expert group explicitly left cost out of the equation, Americans as a whole can’t afford the same luxury, Truog writes.

“Screening mammography for women in their 40s is clearly effective. The problem is that the benefit is tiny and expensive. … Statistician Donald Berry has calculated that for a woman in her 40s, a decade’s worth of mammograms would increase her lifespan by an average of 5 days – and this survival advantage would be lost if she rode a bicycle for 15 hours without a helmet (or 50 hours with a helmet).”

The Obama administration – supposed backer of cost-cutting “death panels” – doesn’t want to invoke what Truog calls the “R” word, and neither do Americans. But healthcare reform will never succeed if we don’t own up to the reality of rationing, he writes.

“Rationing is not a four-letter word. No health care system in the world, including our own, is free from the necessity of rationing. As long as a health care system has anything less than an infinite budget, there is a need to decide which types of health care will be funded and which will not.”

Seen in this light, the vitriol directed at the task force is understandable, but misguided, Truog writes:

“The choice is not between health care rationing and some undefined alternative, since there is no alternative. Rather, the choice concerns what principles we will use to ration health care. In the United States, we have traditionally rationed health care in the same way we ration expensive cars: those who can afford to pay for them are those who can have them. The alternative currently being considered in health care reform would involve a shift to other principles, such as those rooted in considerations of fairness, efficiency, and efficacy.”

-- Karen Kaplan

Photo: Are mammograms for women in their 40s with an average risk of breast cancer the best use for limited healthcare dollars? Credit: Rui Vieira/AP Wire

Why there may be fewer breast cancer 'survivors' in the future

If women and their doctors ultimately follow the advice of the U.S. Preventive Services Task Force and delay their first mammogram until the age of 50, we will likely hear fewer stories of breast cancer “survivors.”

That’s not because there will be more women who don’t realize they have breast cancer until their tumors are too big to treat (though that is probably an inevitable consequence of pushing back the starting age by 10 years).

Rather, it’s because a good number of the women who are diagnosed with breast cancer in their 40s after getting a mammogram – and subsequently go on to “beat the disease” after grueling treatment – would have wound up cancer-free even without treatment. But if they had never known that the cancer was there in the first place, they wouldn’t describe themselves as cancer “survivors” when it was all over.

This prediction comes from Nancy Berlinger, a healthcare bioethicist at The Hastings Center, a bioethics research institute in Garrison, N.Y., who was quoted in Saturday’s story about the downside of widespread cancer screening.

If it comes to pass, it may be seen as evidence that the task force is off its rocker (to put it kindly) by the legions of breast cancer survivors and other vehement critics who assailed the new mammography guidelines when they were released last week. But that won’t necessarily be accurate, Berlinger said.

She points out that even women who are diagnosed with stage 0 ductal carcinoma in situ are treated as if they have breast cancer. Doctors know that some of these cases would never become life-threatening, but since they don’t know which patients fall into that category, all women are treated aggressively. Though that strategy has certainly saved lives, for some women it does more harm than good.

“None of the things we do in cancer treatment are without burden,” she said. “They’re very harsh things to do.”

There are other downsides too.

“Once you make somebody a cancer patient, you can’t un-make them,” Berlinger said. Even for survivors, “that’s a heavy burden in and of itself.”

-- Karen Kaplan

For mild dysplasia and cervical cancer, you can blame HPV

Mild cellular changes detected by Pap smears don't necessarily lead to cancer, a fact that played a role in the new pullback on cervical cancer screening, but both cell changes and cervical cancer can be traced to human papillomavirus.

As today's story noted: "Human papillomavirus, or HPV, which causes cervical cancer and infects half of all young women within a few years of sexual activity's start, also causes cell changes called dysplasia. Those abnormal cells are typically removed before they become cancerous. But such treatment may not be necessary."

Here's an overview of cervical dysplasia from the Women's Health Channel. It notes that up to 70% of mild cases resolve on their own.

The likelihood of progression depends on the amount of dysplasia. Here's what the site says about the stages.

And here are some questions and answers about human papillomaviruses, which have also been linked to cancers of the anus, penis, vulva and vagina -- and to genital warts. The information is from the National Cancer Institute. Of note: There are more than 100 types of HPV;  some are considerably more likely to cause cancer than others.

It states: "Both high-risk and low-risk types of HPV can cause the growth of abnormal cells, but only the high-risk types of HPV lead to cancer. Sexually transmitted, high-risk HPVs include types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 73. These high-risk types of HPV cause growths on the cervix that are usually flat and nearly invisible, as compared with the external warts caused by low-risk types HPV–6 and HPV–11. HPV types 16 and 18 together cause about 70% of cervical cancers."

The Gardasil vaccine can protect against some, including types 16 and 18, but not all.

-- Tami Dennis

Photo: The HPV vaccine protects against four strains.

Credit: European Pressphoto Agency

Here's who should really worry about cervical cancer, doctors say

 The new cervical cancer screening recommendations might worry some women accustomed to getting screened every year. They shouldn’t, most doctors say.

 Today's story: Group recommends less frequent Pap tests 

The women who should be worried, physicians point out, are those who remain under-screened.

Half of the women who die from cervical cancer never had a Pap test, and 10% had not been screened in the five years before detection.

Overall, about 20% of U.S. women don’t get regular Pap tests, and 40% fail to get regular mammograms, said Dr. Edward Partridge, an oncologist at the University of Alabama, Birmingham. He’s the chairman of the cervical cancer screening guidelines panel for the National Comprehensive Cancer Network.

“The biggest problem is women who don’t get screened at all,” he said. “That is where your breast cancer is. That is where your cervical cancer is.”

-- Shari Roan