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Cancer, In the News, NIH, Research, Stanford News, Women's Health

NIH Director highlights Stanford research on breast cancer surgery choices

NIH Director highlights Stanford research on breast cancer surgery choices

The director of the NIH, Francis Collins, MD, this morning weighed in on a topic that has garnered much attention lately: the type of surgery that women diagnosed with breast cancer choose. The post, found at the NIH Director’s blog, describes a recent study by Stanford researchers published earlier this month in the Journal of the American Medical Association that examined survival rates after three different types of breast cancer surgery for women diagnosed with cancer in one breast: a lumpectomy (removal of the just the affected tissue, usually followed by radiation therapy), a single mastectomy (removal of the whole affected breast), and double mastectomy (removal of the unaffected breast along with the affected one.)

In a previous post we wrote in detail about the study and the finding that the number of double mastectomies in California have increased dramatically. However, except for women with the BRCA1 or BRCA2 genes, the procedure does not appear to improve survival rates for women who undergo the surgery compared with women who choose other types of breast surgery. Collins notes:

It isn’t clear exactly what prompted this upsurge in double mastectomy, which is more expensive, risky, and prone to complications than other two surgical approaches. But [researchers] Kurian and Gomez suggest that when faced with a potentially life-threatening diagnosis of cancer in one breast—and fears about possibly developing cancer in the other—women may assume that the most aggressive surgery is the best. The researchers also said it’s also possible that new plastic surgery techniques that achieve breast symmetry through bilateral reconstruction may make double mastectomy more appealing to some women.

Despite its recent upsurge in popularity, the study found double mastectomy conferred no survival advantage over the less aggressive approach of lumpectomy followed by radiation.

Collins also points out that the slightly worse survival rates of women who undergo single mastectomies probably reflect the fact that poorer women were more likely to have this surgery and is evidence of yet another health disparity linked to economic status.

Previously: Breast cancer patients are getting more bilateral mastectomies – but not any survival benefit

Health Costs, Research, Women's Health

Menopausal symptoms tied to lost work productivity, higher health-care costs

Menopausal symptoms tied to lost work productivity, higher health-care costs

Previous studies have shown that hormone therapy, a common treatment for menopausal symptoms such as hot flashes, can lead to a higher risk of breast cancer, heart disease, stroke and blood clots in some women. For that reason, many women no longer use the treatment for their symptoms.

Now, a study from Yale School of Medicine researchers has highlighted the economic consequences of this aspect of menopause, with hot flashes being tied to lost productivity at work and to increased health-care costs. Medical News Today reports on the findings (subscription required), which appear in the journal Menopause:

[The research team] used data on health insurance claims to compare over 500,000 women, half with and half without hot flashes. The team calculated the costs of health care and work loss over a 12-month period. Participants were all insured by Fortune 500 companies.

The team found that women who experienced hot flashes had 1.5 million more health care visits than women without hot flashes. Costs for the additional health care was $339,559,458. The cost of work lost was another $27,668,410 during the 12-month study period.”

“Not treating these common symptoms causes many women to drop out of the labor force at a time when their careers are on the upswing,” Philip Sarrel, MD, said in the piece, later adding that there are options for those suffering: “The symptoms can be easily treated in a variety of ways, such as with low-dose hormone patches, non-hormonal medications, and simple environmental adjustments such as cooling the workplace.”

Jen Baxter is a freelance writer and photographer. After spending eight years working for Kaiser Permanente Health plan she took a self-imposed sabbatical to travel around South East Asia and become a blogger. She enjoys writing about nutrition, meditation, and mental health, and finding personal stories that inspire people to take responsibility for their own well-being. Her website and blog can be found at www.jenbaxter.com.

Previously: Studying the link between post-menopausual hormones, cognition and moodAnxiety, poor sleep, and time can affect accuracy of women’s self-reports of menopause symptoms  and Most physicians not prescribing low-dose hormone therapy 

Cancer, Research, Stanford News, Surgery, Women's Health

Breast cancer patients are getting more bilateral mastectomies – but not any survival benefit

Breast cancer patients are getting more bilateral mastectomies - but not any survival benefit

woman looking out window2The most common cancer diagnosis you or a woman you love is likely to receive is early stage breast cancer, probably after detection by mammogram. One would think that given the regularity with which it’s diagnosed, treatment options for early stage breast cancer would be streamlined. Unfortunately, this isn’t the case.  There’s a staggeringly large menu of potential surgeries and treatments from which a patient and her doctor must choose, each with their own risks and benefits. Not including all of the different hormone blocking and chemotherapies, patients must pick one of three surgeries, shown here in order of escalating invasiveness and risk of complication:

  • Breast-conserving surgery (removal of the tumor only), followed by radiation
  • Single mastectomy (removal of the entire affected breast and any affected lymph nodes)
  • Bilateral mastectomy (the above plus the the unaffected breast)

One also would assume that the medical evidence base providing the benefits to the risk/benefit equations for each surgery would be large and up-to-date. Surprisingly, it is not. The randomized trials comparing lumpectomy and single mastectomy were conducted 30 years ago, and they showed similar risks of death. There has not been (and probably will never be) a randomized trial comparing bilateral mastectomy to one of the less invasive choices for healthy women. Angelina Jolie and other women positive for the breast cancer genes (BRCA1 and BRCA2) are in a different situation. For these women, clinical studies have observed a survival benefit after prophylactic mastectomy. For the 99 percent of women without mutations in these or other high-risk genes, existing trial data do not speak to current trends.

Even after accounting for [numerous factors], we found no evidence of lower mortality for women who had bilateral mastectomy in comparison to breast-conserving surgery

The complexity of choosing a breast cancer surgery – and how evidence should play into that choice – has been a hot topic in the last two months, after the publication of a large study calculating (based on predictive models) that bilateral mastectomy ultimately provides little to no improvement  in life expectancy as compared to a single mastectomy. Soon thereafter, on the New York Times’ opinion page, journalist Peggy Orenstein discussed the emotional reasons why women remove their remaining healthy breast, but firmly labeled bilateral mastectomy as  the wrong approach to breast cancer, saying, “It’s hard to imagine… that someone with a basal cell carcinoma on one ear would needlessly remove the other one ‘just in case’ or for the sake of ‘symmetry’.” Other journalists shared why they chose bilateral mastectomy knowing that it wouldn’t necessarily save their life.

To improve the evidence regarding outcomes after the three surgery types, our team at the Stanford Cancer Institute and the Cancer Prevention Institute of California used one of the largest cancer databases available: the cancer registry for the entire state of California. We tracked all 189,734 women diagnosed with stages 0-III breast cancer from 1998-2011 to learn which surgeries they were undergoing for breast cancer treatment and how long they survived afterwards.  These are all women who should have been eligible for breast conserving surgery with radiation. Our results were published today in the Journal of the American Medical Association today and have already received media attention.

We found that bilateral mastectomy for early stage breast cancer increased from 2 percent in 1988 to more than 12 percent in 2011.  The rate of increase was fastest among women younger than age 40 at diagnosis, among whom over one-third of those diagnosed in 2011 had a bilateral mastectomy. Bilateral mastectomy was more often chosen by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute-designated cancer center; while unilateral mastectomy was more often chosen by non-white women and those with public/Medicaid insurance. Even after accounting for characteristics of the women themselves, their tumor types, and their hospitals, we found no evidence of lower mortality for women who had bilateral mastectomy in comparison to breast-conserving surgery. Surprisingly, we found that women who underwent unilateral mastectomy had higher mortality than those who had the other two surgery types. We concluded that despite the growing popularity of bilateral mastectomy, it likely does not provide a better outcome than a less invasive procedure.

These data and the public response to them underscore the need for more updated and more personalized information regarding outcomes after common surgeries. Ideally, these would be accessible real-time by patients and their doctors in easily-understood formats.

Christina A. Clarke, PhD, is a Research Scientist and Scientific Communications Advisor for the Cancer Prevention Institute of California, and a member of the Stanford Cancer Institute.

Previously: At Stanford event, cancer advocate Susan Love talks about “a future with no breast cancer”, Exploring the reasons behind choosing a double mastectomy and Researchers unsure why some breast cancer patients choose double mastectomies
Photo by Alex

Mental Health, Nutrition, Obesity, Research, Women's Health

Stressed? You could be burning fewer calories

Stressed? You could be burning fewer calories

cupcakesBad news, ladies: Findings (subscription required) recently published in Biological Psychiatry show that women who consumed comfort food while feeling stressed burned fewer calories than their zen-like counterparts.

In the study, Ohio State University researchers quizzed a group of women about what was causing stress in their lives before they ate a caloric meal consisting of eggs, turkey sausage, biscuits and gravy. Scientific American reports:

Turns out that the most stressed women had higher levels of insulin. Which slows down metabolism and causes the body to store fat. And that fat, if not burned off, accumulates in the body.

The women who had reported feeling stressed or depressed in the day before eating the meal burned 104 fewer calories during the seven hours following the meal than women who felt more mellow.

If eating high-calorie comfort food to alleviate stress becomes habitual, the result could be an average weight gain of 11 pounds per year.

So next time you’re feeling overwhelmed and exhausted, you might want to reconsider reaching for a cupcake.

Previously: Learning tools for mindful eating, Mindful eating tips for the desk-bound and Want to curb junk food cravings? Get more sleep
Photo by Class V

Patient Care, Pediatrics, Pregnancy, Stanford News, Women's Health

A prenatal partnership that benefits patients, medical students

A prenatal partnership that benefits patients, medical students

prenatal partnership

Over on the Lucile Packard Children’s Hospital Stanford blog, writer Julie Greicius highlights an elective program at Stanford’s medical school that fosters personal connections between prenatal patients and Stanford medical students. The course is designed to offer doctors-in-training the opportunity, early on, to be on the other side of patient care. Emily Ballenger, who’s expecting twins later this month, and medical student Sunny Kummar have partnered up through the program, with Sunny offering extra support by attending prenatal appointments, the babies’ birth, and the first few pediatric appointments.

Relationship building is fundamental to patient-centered care, and with this program the doctor-to-be has the opportunity to identify with the patient experience in his or her supportive role. Without the pressures of being in the medical provider role, the student has the opportunity to practice listening, empathy and compassion.

The value of programs such as this is that they shift the paradigm of the traditional-doctor patient relationship. The scale is tipped from being purely clinical to one focused more on listening and learning from each other. The patient, the doctor-in-training, and their future patients all stand to benefit.

Ballenger’s obstetrician is Susan Crowe, MD, who has long supported the program. “I encourage my patients to participate because it’s a win for future care of obstetric and pediatric patients,” she says in the piece. “I really believe that the patient-centered care we strive for can be better achieved if we train our physicians to really learn from and listen to our patients themselves. One of the biggest strengths of the program is that the patient perspective comes first. It sets the groundwork for that way of thinking in terms of training our medical students.”

Medical schools around the country offer similar programs, recognizing that it’s the human connection that initially draws young doctors to medicine, and Stanford has offered this program since at least 1991. The course directors are Yasser El Sayed, MD, obstetrician-in-chief at Stanford Children’s Health, and Janelle Aby, MD, clinical associate professor of pediatrics.

Jen Baxter is a freelance writer and photographer. After spending eight years working for Kaiser Permanente Health plan she took a self-imposed sabbatical to travel around South East Asia and become a blogger. She enjoys writing about nutrition, meditation, and mental health, and finding personal stories that inspire people to take responsibility for their own well-being. Her website and blog can be found at www.jenbaxter.com.

Previously: Countdown to clinics: The 5 best things about jumping into third year
Photo courtesy of Lucile Packard Children’s Hospital

Aging, Genetics, Imaging, Immunology, Mental Health, Neuroscience, Research, Women's Health

Stanford’s brightest lights reveal new insights into early underpinnings of Alzheimer’s

Stanford's brightest lights reveal new insights into early underpinnings of Alzheimer's

manAlzheimer’s disease, whose course ends inexorably in the destruction of memory and reason, is in many respects America’s most debilitating disease.  As I wrote in my article, “Rethinking Alzheimer’s,” just published in our flagship magazine Stanford Medicine:

Barring substantial progress in curing or preventing it, Alzheimer’s will affect 16 million U.S. residents by 2050, according to the Alzheimer’s Association. The group also reports that the disease is now the nation’s most expensive, costing over $200 billion a year. Recent analyses suggest it may be as great a killer as cancer or heart disease.

Alarming as this may be, it isn’t the only news about Alzheimer’s. Some of the news is good.

Serendipity and solid science are prying open the door to a new outlook on what is arguably the primary scourge of old age in the developed world. Researchers have been taking a new tack – actually, more like six or seven new tacks – resulting in surprising discoveries and potentially leading to novel diagnostic and therapeutic approaches.

As my article noted, several Stanford investigators have taken significant steps toward unraveling the tangle of molecular and biochemical threads that underpin Alzheimer’s disease. The challenge: weaving those diverse strands into the coherent fabric we call understanding.

In a sidebar, “Sex and the Single Gene,” I described some new work showing differential effects of a well-known Alzheimer’s-predisposing gene on men versus women – and findings about the possibly divergent impacts of different estrogen-replacement  formulations on the likelihood of contracting dementia.

Coming at it from so many angles, and at such high power, is bound to score a direct hit on this menace eventually. Until then, the word is to stay active, sleep enough and see a lot of your friends.

Previously: The reefer connection: Brain’s “internal marijuana” signaling implicated in very earliest stages of Alzheimer’s pathology, The rechargeable brain: Blood plasma from young mice improves old mice’s memory and learning, Protein known for initiating immune response may set up our brains for neurodegenerative disease, Estradiol – but not Premain – prevents neurodegeneration in woman at heightened dementia risk and Having a copy of ApoE4 gene variant doubles Alzheimer’s risk for women, but not for men
Illustration by Gérard DuBois

Health Disparities, Men's Health, Public Health, Research, Stanford News, Women's Health

Why it’s critical to study the impact of gender differences on diseases and treatments

man_womanWhen it comes to diagnosing disease and choosing a course of treatment, gender is a significant factor. In a Stanford BeWell Q&A, Marcia Stefanick, PhD, a professor of medicine at the Stanford Prevention Research Center and co-director of the Stanford Women & Sex Differences in Medicine Center, discusses why gender medicine research benefits both sexes and why physicians need to do a better job of taking sex difference into consideration when make medical decisions.

Below Stefanick explains why a lack of understanding about the different clinical manifestations of prevalent diseases in women and men can lead to health disparities:

…Because we may have primarily studied a particular disease in only one of the sexes, usually males (and most basic research is done in male rodents), the resulting treatments are most often based on that one sex’s physiology. Such treatments in the other sex might not be appropriate. One example is sleep medication. Ambien is the prescription medicine recently featured on the TV show, 60 Minutes. Reporters found out that women were getting twice the dose they should because they had been given the men’s doses; consequently, the women were falling asleep at the wheel and having accidents. Physicians had not taken into account that women are smaller and their livers’ metabolize drugs differently than do men’s. Some women have responded by reducing their own medication dosages, and yet that practice of self-adjusting is not the safest way to proceed, either.

Previously: A call to advance research on women’s health issues, Exploring sex differences in the brain and Women underrepresented in heart studies
Photo by Mary Anne Enriquez

Parenting, Sleep, Women's Health

What other cultures can teach us about managing postpartum sleep deprivation

What other cultures can teach us about managing postpartum sleep deprivation

New_mom_072114Prior to becoming a mom, I felt fully confident that caring for a newborn would be less demanding than, or at least equal to, the physically grueling trainings from my college soccer days or my sleepless year of graduate school. But I soon learned that both of these experiences paled in comparison to the exhaustion I encountered after the arrival of my 8-pound-plus bundle of joy. So I was interested to read a recent Huffington Post blog entry from the Stanford Center for Sleep Sciences and Medicine examining how mothers in other countries cope with postpartum sleep deprivation.

In the entry, Mara Cvejic, MD, a neurologist at the University of Florida and former sleep medicine fellow at Stanford, notes that although sleep deprivation can profoundly affect cognitive function and mood, the brain of a postpartum mom is actually growing. She writes:

… despite all the formidable evidence of sleep deprivation in the everyday person, the scientific evidence of what happens to the postpartum brain is positively astounding — it thrives. A study published by the National Institutes of Health in 2010 actually shows that a mother’s brain grows from just 2-4 weeks to 3-4 months post delivery without any significant learning activities. The gray matter of the parietal lobe, pre-frontal cortex, hypothalamus, substantia nigra, and amygdala all form new connections and enlarge to a small degree. The imaging study confirms what animal studies have shown in the past — that these brain regions responsible for complex emotional judgment and decision-making actually bulk up with use. Rationale to the study shows that mothers who have positive interactions with their offspring — soothing, nurturing, feeding, and caring for them — are performing a mental exercise of sorts. Their learned coping skills in the face of novel child-rearing actually muscularize their brain.

She goes on to outline how new moms from Bulgaria to Sweden, and everywhere in between, turn to “hammocks, spa treatments, hired help, warm foods, arctic cradles, and cardboard” to cope with a lack of sleep. Personally, I’m in favor of Americans adopting this Malaysian tradition:

Food and warmth are also a focus of the Malaysian confinement of pantang. Steeped in the belief that the women’s life force is her fertile womb, she undergoes a 44-day period of internment to focus on relaxation, hot stone massage, lulur (full body exfoliation), herbal baths, and hot compresses. Typically a bidan, what can only be described as a live-in midwife and nanny combined, is hired to attend on the new mother. This is sometimes a family member, such as her mother or mother-in-law.

Previously: The high price of interrupted sleep on your health, What are the consequences of sleep deprivation? and Study: Parents may not be as sleep-deprived as they think
Photo by sean dreilinger

Parenting, Pregnancy, Technology, Women's Health

First-time moms often seek information online prior to first prenatal visit

First-time moms often seek information online prior to first prenatal visit

pregnant_laptopWhen I was eight weeks pregnant with my first child, I walked into my obstetrician’s office for my initial prenatal visit. I vividly remember being exhausted and sucking on watermelon lollipops for the entire two-hour appointment in an effort to relieve my morning sickness. While in the office, a nurse handed me a thick folder stuffed with various pamphlets and fact sheets on everything from nutrition to genetic testing – but much of the information reviewed wasn’t new to me. I’d already logged plenty of hours online reading about such topics.

So I was interested to read today about findings of a Penn State study showing that many other first-time moms also turn to “Dr. Google,” as well as social media, to find answers during the early weeks of their pregnancy. Women also continued turning to the Internet for information after their doctor visit and found traditional literature lacking. From a release on the study, which appears in the Journal of Medical Internet Research:

Following the women’s first visit to the obstetrician, many of them still turned to the internet—using both search engines and social media—to find answers to their questions, because they felt the literature the doctor’s office gave them was insufficient.

Many of the participants found the pamphlets and flyers that their doctors gave them, as well as the once-popular book What to Expect When You’re Expecting, outdated and preferred receiving information in different formats.

They would rather watch videos and use social media and pregnancy-tracking apps and websites.

“This research is important because we don’t have a very good handle on what tools pregnant women are using and how they engage with technology,” says [Jennifer Kraschnewski, MD]. “We have found that there is a real disconnect between what we’re providing in the office and what the patient wants.”

Noting the prevalence of misinformation online, Kraschnewski added, “We need to find sound resources on the Internet or develop our own sources” [to refer patients to].

Previously: Text message reminders shown effective in boosting flu shot rates among pregnant women and Examining the effectiveness of text4baby service
Photo by Adam Selwood

Pain, Pregnancy, Stanford News, Women's Health

Study shows women prefer less-intense pain at the cost of a prolonged labor

Study shows women prefer less-intense pain at the cost of a prolonged labor

child_birthAs a friend’s due date approached, she confided in me that the thought of going into labor was terrifying. It was her first pregnancy and we debated at length the pros and cons of having an epidural for pain management. Her main concern, like others, was that the common method of pain relief could prolong labor. Recent findings have shown that an epidural can lengthen the second-stage of labor for more than two hours.

In the end, she decided her birth plan needed to be flexible and include the option of an epidural, regardless of how it may impact the length of her labor. New research shows many would agree. Brendan Carvalho, MBBCh, chief of obstetric anesthesia at Stanford and lead author of the study, told Reuters that “Interestingly, intensity is the driver” behind women’s labor preferences.

More from the article:

For the study, Carvalho and his colleagues gave a seven-item questionnaire to expectant mothers who had arrived at the hospital to have labor induced but were not yet having painful contractions. The women took the survey a second time within 24 hours of giving birth.

The questionnaire pitted hypothetical pain level, on a scale of zero to 10, against hours of labor.

A sample question asked, “Would you rather have pain intensity at two out of 10 for nine hours or six out of 10 for three hours?”

Both pre- and post-labor, women on average preferred less intense pain over a longer duration, according to results published in the British Journal of Anaesthesia.

Previously: From womb to world: Stanford Medicine Magazine explores new work on having a baby
Photo by Mamma Loves

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