Too Old For a Mammogram?

When to stop screening? My 85 year old patient was ‘disappointed’ that I turned down her request for a mammogram requisition slip. Her mammogram was a birthday ritual and had been for decades. She had no unusual risk factors for breast cancer and performed breast-self examinations monthly. While a matter of debate, finding breast cancer at age 85 may not help my patient survive longer, but it may cause medical problems, diminish her quality of life and cause unnecessary distress.

There is no doubt that screening mammograms will pick cancers at an earlier stage. The question of what to do if a cancer is found will be based on type of cancer, if there are other medical conditions, expected life expectancy and the wishes of the patient. Most of the studies that looked at women who had screening mammography after age 80 have found that those women tended to be white, married, and have higher education and income levels. They also were in better health with fewer other conditions such as heart disease or diabetes. The data are not clear if early detection of breast cancer in elderly women increase survival. For women with other medical problems (lung disease, peripheral vascular disease, heart disease, diabetes, rheumatologic disease), mammograms did not increase survival.

This discussion is about screening mammograms only. Any breast mass or breast change requires an evaluation – which could include mammogram, ultrasound or MRI.

I read an excellent guideline – women should have a yearly screening mammogram until they believe that they don’t have ten good years left.

Prostate Cancer Screening

To screen or not to screen? The recurrent question for my older male patients.

Prostate cancer is common and most men will develop it if they live long enough. Dr. Andrew Vickers of Memorial Sloan Kettering Cancer Center wrote some excellent guidelines to help guide the choice

In summary:

The goal of screening is to find aggressive prostate cancer early and cure it before it spreads beyond the prostate.

Most cancer cases found by screening do no need to be treated and can be managed by “active surveillance.”

If you choose to be screened, there is a good chance that you will be diagnosed by with a low-risk cancer and you may face pressure from your physicians or family to treat it.

The entire short and easy to read article is available on line. You may need to read it at the library or ask your internist to access it for you.

Choose My Plate

We all have to eat – and more than once per day! Not too many of us are presented with an attractive, delicious and nutritionally perfect plate; it takes some effort to get there. An excellent resource is Choose My Plate from the United States Department of Agriculture.

The website provides abundant resources for families on a budget, dieters, children and healthcare professionals.

Controlled Substances

Controlled substances are not only drugs of abuse, but include medications that have a useful and legitimate purpose. In addition to narcotics, the class includes certain hormones, anti-seizure medications, stimulants and depressants. Physicians who write prescriptions for controlled substances need special licenses from both federal and state governments.

Prescription medication overdose is an increasing problem. Drug overdose was the leading cause of injury death in 2012. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes. In 2011, drug misuse and abuse caused about 2.5 million emergency department (ED) visits. Of these, more than 1.4 million ED visits were related to pharmaceuticals.

Teenagers are at particular risk. They obtain the pharmaceuticals from friends and relatives, sometimes without the person knowing. (What’s in your medicine cabinet?) The good news is that teens as a group are less likely to die of an overdose since adults abuse drugs at a greater rate.

Current estimates show that controlled substances comprise 12 percent of all prescriptions made each year. Every year a greater number of prescriptions are sent electronically directly to the pharmacy, more than 75% in most states. At this time, we cannot use e-prescribing for controlled medications. Prescriptions are printed or hand-written on tamper-proof paper using precise metrics. This is annoying to the prescriber but can be a real burden to the patient who needs medication.

Fact Sheet on drug overdoses.

The science behind drug abuse.

2x2: Two Minutes Twice per Day

Teeth are the only non-shedding surface in the body.  Bacterial levels in dental plaque can reach very high levels and can easily spread to the blood stream. Periodontal (gum) disease can facilitate the spread of the bacteria.

Dental disease can lead to loss of teeth and jaw damage. Periodontal disease has been associated with heart disease, possibly due to increased amount of bacteria introduced into the blood stream. The resulting chronic inflammation can start a chain of events that lead to artery blockage. Other conditions that may be related to chronic periodontitis are difficult to control diabetes and pneumonia.

Adult dental care is as important now as it is for kids. Everyone should brush teeth for two minutes twice per day as well as floss once per day. Use a soft toothbrush. Contrary to what toothpaste commercials show, the amount of paste or gel does not have to be a heaping amount. A pea-sized dab is plenty. Unless there is a reason otherwise, buy toothpaste with fluoride.

If brushing is impossible, rinse with warm salty water after eating.

A refresher.

E-Cigarettes

E-cigarettes are a nicotine delivery system to the lungs that doesn’t involve the carcinogenic byproducts of burning tobacco leaves. Rather, a liquid nicotine solution is vaporized into steam that is inhaled. There has been no association to date of e-cigs with cancer, but that doesn’t mean that they are a good idea.

As a replacement for regular cigarettes, e-cigs might be a public health win by reducing lung cancer but the risk of cardiovascular disease would remain. Nicotine constricts blood vessels, increasing blood pressure and reducing delivery of oxygen-rich blood. Unlike conventional cigarettes, there is no learning to inhale or initial coughing bouts leading to concern that e-cigs might be the gateway to other tobacco use, especially for teens. E-cigs are so easy to use that one reviewer said that she could smoke them while on the treadmill.

E-cigs come in a variety of ‘flavors’ and different concentrations of nicotine. Nicotine is known to improve mood and many find it an effective appetite suppressant. There is a small amount of contested evidence that it might delay the start of Alzheimer’s disease – not a reason to start using nicotine in any form.

Another danger of e-cigs is that it might become socially acceptable to use them indoors, exposing others to the nicotine-laced steam. New York City, among other places, limits the use of e-cigs the same way as conventional cigarettes including the proscription against use in outdoor public places.

Both tobacco companies and pharmaceutical companies have financial interests in e-cigs, but the final say lies with both regulators and the users. If society thinks that smoking is a bad idea the type of nicotine delivery won’t matter.