Women’s Health

With conversations still fresh in the air about Angelina Jolie’s decision to remove her healthy breasts as a protective measure against a high probability of cancer, Susan Love, MD, cancer survivor and author of the best-selling book on breast cancer, couldn’t have been a more apt keynote speaker at the fourth annual Stanford Women’s Health Forum yesterday. She gave a forward-looking talk titled “A Future Without Breast Cancer: Where Are We and What Can We Do.”

We don’t understand the normal breast… If we’re really going to prevent breast cancer, we have to understand it

The forum was an event focused broadly on women’s health issues, but breast cancer and cancer survivorship were major topics – with many of the 400 attendees also hearing from Mark Pegram, MD, director of Stanford’s breast cancer program, and Allison Kurian, MD, an assistant professor of oncology at Stanford whose research is focused on hereditary breast cancer. (Kurian, in fact, had spent much of her day Tuesday answering questions from the press about Jolie.)

Love, who told the New York Times yesterday that she wants people to understand that “we really don’t have good prevention for breast cancer,” described to the audience how the state of knowledge about the breast and breast cancer is far from adequate. She said:

We don’t understand the normal breast… You’d think we’d know, but we really don’t. That’s a whole area that’s been ignored and it’s another thing we have to push people to do – to not just look at the disease. If we’re really going to prevent it, we have to understand how it works, to figure out what the early changes are. Isn’t it a shame that the only thing Angelina has to do, knowing she has the (mutant) gene, is to have a normal body part cut off – because we don’t know how to prevent breast cancer?

…

We’ve got awareness. We don’t have to work on that; we have to go beyond that to be part of finding the solution, to demand better research and to be part of it. I think we can be the generation that ends breast cancer.

Videos of this and other talks will be posted soon on the Stanford Center for Health Research on Women and Sex Differences in Medicine (WSDM) website.

Previously: Breast cancer advocate Susan Love to deliver keynote at Stanford Women’s Health Forum, Stanford’s Mark Pegram discusses breast cancer in the genomic age, Helping inform tough cancer-related decisions, BRCA patients use Stanford-developed online tool to better understand treatment options and A closer look at preventive breast cancer surgery

As part of efforts to promote exclusive breastfeeding, many hospitals are reducing their use of baby formula for newborns. But – as is being widely reported today – a new study published online in Pediatrics suggests that a strict no-formula approach in the early days of breastfeeding may sometimes amount to throwing the baby out with the bathwater.

The study focused on a problem that often derails moms’ early efforts to breastfeed: Early weight loss among newborns may prompt some mothers to switch from breastfeeding to formula-feeding because they worry that their babies aren’t getting enough to eat. Using a little bit of formula in a carefully controlled way may help these moms to stick with breastfeeding in the long run, the study found.

Here’s the back story: In the first three days after birth, instead of making milk, women produce small amounts of a fluid called colostrum. Colostrum is really good for babies, but there isn’t much of it, so it’s normal for babies to lose some weight before full-scale milk production begins. But if a baby loses more than five percent of his or her birth weight, doctors and moms can both get worried – especially if the mother’s milk is a bit slow to come in, or if the baby seems especially hungry or fussy.

Stanford/Packard Children’s pediatrician Janelle Aby, MD, who collaborated on the new study with a team of scientists at the University of California-San Francisco, told the San Francisco Chronicle:

In the first three days or so, the key complaint we hear is ‘I’m concerned I don’t have enough milk. I’m worried my baby is starving,’ ” said [Alby]. “Then we do daily weighs and it’s dropping and dropping, and that’s very stressful. Some moms, they get to a place where they can’t take it anymore and they give the baby formula.”

Yet giving formula at this point can derail breastfeeding completely – with a tummy full of formula, the baby may not be hungry enough to nurse. And using a bottle in the early days can cause “nipple confusion,” in which the baby finds the bottle easier to drink from and subsequently won’t take the breast.

The research team thought there might be a possible middle ground. They wondered if they could use just a little bit of judiciously delivered formula to help boost breastfeeding efforts. They taught mothers whose babies had lost at least five percent of their birth weight to supplement breastfeeding with small amounts of formula fed by syringe. The idea was to give hungry babies a little boost without feeding so much formula that they’d stop wanting to nurse. Using a syringe prevented nipple confusion. And once the moms’ milk came in, the formula supplements stopped.

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As a reminder, today is the final day of our Ask Stanford Med installment focused on breast cancer. Questions related to breast cancer screening, dense breast notification legislation and advances in diagnostics and therapies can be submitted to Stanford surgeon Fredrick Dirbas, MD, by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section of our previous entry. We’ll accept questions until 5 p.m. Pacific time.

We provided details about Dirbas’ clinical work and research in our earlier post:

As head of the Breast Disease Management Group at the Stanford Women’s Cancer Center, Dirbas works with an interdisciplinary team of radiologists, oncologists, pathologists, researchers and support programs to provide patients with a comprehensive treatment approach. His research focuses on improving breast cancer therapy by refining existing diagnostic and treatment options and introducing new methods that reduce side effects and improve patients’ quality of life.

A 2011 Stanford Hospital Health Notes article describes how Dirbas and colleagues are at the forefront of exploring new ideas for delivering radiation in a more targeted and accelerated fashion, including methods such as intraoperative radiotherapy and another approach using external radiation therapy after surgery.

Previously: Ask Stanford Med: Surgeon taking questions on breast cancer diagnostics and therapies, California’s new law on dense breast notification: What it means for women and Five days instead of five weeks: A less-invasive breast cancer therapy
Photo by Wellcome Images

My best friend finally succeeded in his efforts to stop smoking when he experienced a highly motivating life change: Fatherhood. Likewise, many women discover that wanting to have a safe and healthy pregnancy gives them unprecedented desire to kick their tobacco habit. Knowing the research and clinical evidence may be useful to parents-to-be who have some questions about smoking:

1. Quitting smoking is very hard – does it really make enough difference to be worth it?  Yes. To get one sense of the impact of smoking on fetal development, recall the widespread panic in the 1980s about “crack cocaine babies.” Subsequent research has shown that the damage to fetuses of cigarette smoking is in fact worse than that of crack cocaine use. Even if it didn’t benefit the fetus (and later, the infant) for a mother to quit smoking, it would still be worth using the extra motivation to quit that pregnancy provides for the sake of the mother’s long term health.
2. When is the best time to try to quit? Early. In an excellent lecture I saw last week, Professor Zachary Stowe, MD, with the University of Arkansas for Medical Sciences, pointed out that the soonest a woman can know she is pregnant is 4-6 weeks after conception, at which point fetal organogenesis is well underway. Further, Stowe and other researchers have conducted research identifying nicotine and its metabolites in the fetal compartment even after the mother has stopped smoking. Dr. Stowe therefore suggests that rather than waiting to quit until after stopping birth control or after pregnancy has been confirmed by a test, a mother-to-be should wait two weeks after quitting smoking before going off birth control. Note: Even if you didn’t do this, quitting smoking at any point later in the pregnancy is still good for the fetus (and for you too).
3. I smoke, but I’m not carrying the baby, so why does it matter whether I quit? This isn’t just about mom. Passively absorbed smoke contributes to nicotine in the fetal compartment, meaning that even if the mother quits, smoking by her partner may affect the fetus. Also, an added benefit to a couple of quitting together is suggested by research and clinical experience in addiction treatment: Relapse is more likely when the visible, auditory and olfactory cues of substance use remain in the environment. Hence, a mom-to-be is going to have a much harder time quitting cigarettes if her partner remains a smoker. More positively, if two people quit together they can remove those cues from the environment and also have built-in social support for resisting the cravings they both may experience.
4. Where can we get help with smoking cessation? Free resources are just a click away here. If you need extra support, consult your physician, who can help you both with smoking cessation and with other conditions you may have (e.g., depression) that make it hard to quit.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Previously: Craving a cigarette but trying to quit? A supportive text message might help, Exercise may help smokers kick the nicotine habit and remain smoke-free, Kicking the smoking habit for good and Can daily texts help smokers kick their nicotine addiction?
Photo by YOUscription

A founding mother of the breast cancer advocacy movement, Susan Love, MD, will kick off this year’s Stanford Women’s Health Forum with a talk, “A Future Without Breast Cancer: Where Are We and What Can We Do,” at the May 15 event.

Love is a clinical professor of surgery at UC Los Angeles and president of the Dr. Susan Love Research Foundation. After dedicating years of her life to patient advocacy, she became a patient herself when she was diagnosed with acute myelogenous leukemia last year; she recently shared her experiences as a patient on a New York Times blog.

In addition to Love, the free community event will feature experts from throughout the School of Medicine. From our release:

Previous health forums have been “an opportunity for people in the community to learn about important medical issues affecting women and about the groundbreaking research done at Stanford,” said Lynn Westphal, MD, associate professor of obstetrics and gynecology… “At this year’s forum, anyone who has been touched by cancer, either personally or through a loved one, will benefit from the discussions.”

Other speakers at the forum will discuss a variety of topics, including breast cancer diagnosis, risk and surgery; headaches during sexual activity; contraception; stress and survivorship; lung cancer in nonsmokers; cancer-related sleep problems; weight-loss diets; colorectal screening and cancer; facial rejuvenation; and sunscreen and skin cancer prevention. Among the Stanford speakers will be headache specialist Robert Cowan, MD, clinical professor of neurology and neurological sciences; oncology professor Mark Pegram, MD, who directs Stanford’s breast cancer program; and nutrition researcher Christopher Gardner, PhD, associate professor of medicine.

The forum is being presented by the Stanford Center for Health Research on Women & Sex Differences in Medicine (known as the WSDM Center). Registration for the half-day event is now open.

Previously: A call to advance research on women’s health issues, Exploring sex differences in the brain, Stanford 2011 Women’s Health Forum videos available on the web, Women’s Health Forum videos online and Nancy Snyderman speaks at Stanford Women’s Health Forum

Near the end of a woman’s pregnancy, obstetricians use ultrasound to check that the baby is poised to be born head-first. Since breech vaginal deliveries (with the feet or rear end first) are risky for both mom and child, many physicians opt to schedule a c-section if the baby isn’t head-down at the end of pregnancy.

However, before they take that step, doctors can perform a procedure called an external cephalic version (or simply “version”) to try to turn the baby. To do this, they push on the mother’s pregnant abdomen while carefully monitoring the baby with ultrasound. In the past, women were not given anesthesia during this procedure, but recent research has shown that administering anesthesia can make versions more successful, perhaps because the medications help to relax the women’s abdominal muscles and allow the physician to use less pressure. Unsurprisingly, moms who receive pain relief are also happier with the process than those who don’t.

But there’s a wrinkle: Some physicians have worried about the additional expense of using anesthesia for versions, since the anesthesiologist’s time and the drugs used come with costs. Researchers from Stanford and Lucile Packard Children’s Hospital decided to address this conundrum by analyzing whether the additional cost of anesthesia was offset by the savings from enabling more vaginal deliveries and avoiding some cesareans.

In our press release, Brendan Carvalho, MD, the lead author of the new research, explained the findings:

“[O]ur work shows that it doesn’t add significant costs, and most likely reduces overall costs because more women can avoid cesareans.”

…

The study found that using anesthesia increased average success rates of version procedures from 38 percent to 60 percent. Because it led to fewer cesareans, use of anesthesia also decreased the total cost of delivery by an average of $276; the range of cost differences estimated by the model extended from a $720 savings to a $112 additional cost.

Looking at the question of cost-effectiveness in a different way, the success rates of versions had to be improved at least 11 percent with anesthesia for the cost of the anesthesia to be negated, the researchers calculated.

So far, Carvalho said, Packard Children’s is one of only a few Bay Area hospitals offering anesthesia for versions. But he hopes his team’s findings will encourage more physicians to consider the practice, since it’s good for both mothers’ well-being and hospitals’ bottom lines.

Previously: Should midwives take on risky deliveries?
Photo by Trevor Bair

…Make that lots and lots of freezers.

Freezers storing blood from thousands of generous research volunteers who donate samples when they are healthy – years or even decades before they might develop cancer, diabetes or other chronic diseases – can be found across the country. For scientists, these “pre-diagnostic” blood samples are likely to contain new biological clues of disease, perhaps molecular flags that cancerous cells are multiplying, or immunological rumblings as the immune system responds to the first signs of disease. Finding these signals is critical to future prevention, as they could represent the basis for blood tests or other means of ultra-early detection of disease.

The statistics involved in gathering enough pre-diagnostic blood samples to make them useful to research are daunting, though. For example, to study the blood of 100 women who go on to develop ovarian cancer in the next year, more than 200,000 samples from healthy women must first be stockpiled.

This month, Stanford’s partner, the Cancer Prevention Institute of California, along with their colleagues in Southern California at the City of Hope National Medical Center and UC Irvine, embark on an epic research effort: asking more than 50,000 female teachers, retired teachers and school administrators all over California – participants for the last 16 years in the long-term follow-up California Teachers Study – to provide a blood sample to be stored away for future research. This is no small logistical feat. First, teachers aged 50 to 79 from all over the state will be asked to participate and provide a convenient time and place for a phlebotomist to visit them for a blood draw. The samples will then be express shipped to a state-of-the-art biobank where they will be frozen in large banks of closely monitored freezers, alongside similar samples from other long-term studies.

The Teachers Study will continue its long-standing routines for tracking the health outcomes of each participant by continuously linking their names and other identifying information to California health databases, including death certificates, cancer registries and hospitalization discharge summaries. With time, the stored blood samples will turn into scientific gold, as we learn which of them were drawn from women who later developed cancer. In addition to looking for early proteomic markers of breast, ovarian and other cancers, the samples of women who ultimately developed cancer will undergo intense testing for chemical pollutant levels.

DNA will also be extracted from the blood, and from saliva samples donated by mail from teachers who live too far from the phlebotomists’ routes, or who volunteer to participate in that way. These DNA samples will likely be analyzed with others from very large prospective studies, like the ongoing study of more than 100,000 Northern California Kaiser Permanente members, whose saliva samples have been banked.

Some new clues to cancer can only be discovered when scientists study massive numbers of samples at the same time. To date, gene hunting has yielded a few blockbuster findings – most famously the rare BRCA1 and BRCA2 genes with very high risk for breast cancer - but no common genes or gene combinations amenable to broader risk profiling. This may be because past efforts didn’t have the statistical power to find the most likely culprits, subtle combinations of many gene mutations that together may provide some meaningful differentiator of risk. Very large datasets, containing not thousands but millions of genomes, will be required to establish reliable genomic markers of disease.

Genomic prediction for chronic disease and ultra-early blood tests for cancer aren’t here yet, but they’re getting closer. And when they do arrive, we can thank the volunteers with the foresight to file away their precious blood samples in many, many freezers.

Christina Clarke, PhD, MPH, is a research scientist at the Cancer Prevention Institute of California (CPIC) and a member of the Stanford Cancer Institute. Part of the Stanford Cancer Institute, the Cancer Prevention Institute of California conducts population-based research to prevent cancer and reduce its burden where it cannot yet be prevented.

Photo by Shutterstock

Effective today, radiologists across California will be required by law to notify women when their mammography screening shows they have dense breast tissue. Approximately 50 percent of women have dense breast tissue – more fibrograndular tissue than fatty tissue as seen on a mammogram – so falling into this category is quite normal.

If you’re a woman with dense breast tissue, you’ll receive a letter in the mail that includes an explanation that this is a risk factor for developing breast cancer and that having such tissue may make it more difficult to detect a tumor. (However, having dense breast tissue is only a small risk factor for developing breast cancer and mammography is still considered the gold standard in breast-cancer screening.)

While this notification is meant to educate women about their own bodies and empower them to make better health-care decisions, it could also result in needlessly alarming or confusing patients. It’s important that women understand why they’re receiving this information and what they can do about it, which is why Stanford Hospital prepared the video above.

Here’s a new reason to dislike smog: Air pollution from traffic has been linked to birth defects in a large new Stanford study of women who lived in California’s smoggy San Joaquin valley during the early weeks of their pregnancies.

From our press release on the study:

“We found an association between specific traffic-related air pollutants and neural tube defects, which are malformations of the brain and spine,” said the study’s lead author, Amy Padula, PhD, a postdoctoral scholar in pediatrics. The research appears online today in the American Journal of Epidemiology.

“Birth defects affect one in every 33 babies, and about two-thirds of these defects are due to unknown causes,” said the paper’s senior author, Gary Shaw, PhD, professor of neonatal and developmental medicine. “When these babies are born, they bring into a family’s life an amazing number of questions, many of which we can’t answer.”

The new research focused on five structural birth defects thought to be potentially affected by the mother’s environment during pregnancy, as well as seven pollutants measured during the EPA‘s federally mandated monitoring of air quality. The researchers compared more than 800 women who had a pregnancy affected by a birth defect between 1997 and 2006 to a similar number of women who had healthy babies during the same period. All of the women lived in the San Joaquin valley during their first eight weeks of pregnancy, and each gave the researcher her home address so that her pollution exposure could be estimated using data from nearby EPA air-quality monitoring stations.

The study is just the beginning of researchers’ efforts to understand the effects of traffic pollution on fetal development. Although a few prior studies have suggested a possible link, they have focused on different geographic regions, have produced conflicting results and have had various flaws in their methods. The new study is the first, for instance, to evaluate women’s pollution exposure in early pregnancy, when birth defects are likely to be developing, rather than at birth.

Much work is still needed in this area, the scientists say, including widening the scope of birth defects studied and examining the effects of combinations of pollutants. If future studies support the new findings, they could offer a route for preventing some devastating birth defects.

Previously: Better diet in pregnancy shown to protect against birth defects, NIH study supports screening pregnant women for toxoplasmosis and Federal government tests potential health risks of 10,000 chemicals using high-speed robot
Photo by Lynn Friedman

A large body of scientific research supports the safety and effectiveness of intrauterine devices and other forms of long-acting, reversible contraception (LARC) for adolescents, and physicians should offer these birth control methods to young women in their care. That’s the message behind a series of review articles published this week in a special supplemental issue of the Journal of Adolescent Health.

Stanford ob/gyn expert Paula Hillard, MD, who edited the supplement, explained to me that doctors are missing a great opportunity to prevent unwanted pregnancies by not offering young women the LARC birth control methods, which include IUDs and hormonal implants. Not only are the LARC methods very safe, the rate of unintended pregnancy with typical use of these techniques is 20 times lower than for alternate methods such as the Pill or a hormone patch.

But a design flaw in one specific IUD used in the 1970s – the Dalkon Shield – increased women’s risk for pelvic infections and gave all IUDs a bad rap. Use of IUDs among adult American women has been low ever since; it’s even lower in teens.

“Long after it was proven that the Dalkon Shield was particularly bad and newer IUDs were much safer, women were just scared,” Hillard said. “Not only did women stop asking for for them, many doctors also stopped using IUDs.”

The new review articles that Hillard edited are targeted at physicians but contain some interesting tidbits for general readers as well. The article titled “Myths and Misperceptions about Long Acting Reversible Contraception (LARC)” provides scientific evidence to refute several common myths, concluding, for instance, that IUDs don’t cause abortions or infertility, don’t increase women’s rates of ectopic pregnancy above the rates seen in the general population, and can be used by women and teens who have never had children.

And, as Hillard put it for me during our conversation, “These birth control methods are very safe and as effective as sterilization but completely reversible. They work better than anything else, and they’re so easy to use.”

Previously: Will more women begin opting for an IUD?, Promoting the use of IUDs in the developing world, and Study shows women may overestimate the effectiveness of common contraceptives
Photo, by ATIS547, shows a public sculpture on the campus of the University of California, Santa Cruz that is affectionately known as the “Flying IUD”