Most surgeons still encourage annual, earlier mammograms

mammogram_250_310The vast majority of surgeons continue to recommend that women 40 years old or older with an average risk for breast cancer get annual screenings for the disease. This conflicts with a newly released draft statement from the U.S. Preventive Services Task Force (USPSTF)  and its 2009 recommendations that most women be screened every two years beginning at 50 years old and continuing through age 74.

A team of researchers studying the effectiveness of policy recommendations on practicing surgeons found that 88 percent of breast surgeons and 82 percent of general surgeons continue to recommend annual mammography for women with an average risk of developing breast cancer. An even greater percentage–93 percent–reported that they began or would begin annual screenings for themselves at age 40.

This aligns with American Cancer Society recommendations that most women begin annual screening at age 40 and continue past age 75, barring serious health problems.

“We found that the majority of surveyed breast surgeons advocate and personally follow the screening mammography recommendations of the American Cancer Society, the American College of Radiology, and the Society of Breast Imaging, instead of those of the USPSTF,” said coauthor Vilert Loving, director of breast imaging at the Banner MD Anderson Cancer Center.

According to the USPSTF guidelines:

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms. 

Study coauthors Jiyon Lee (NYU Cancer Institute) and Elaine Tanaka (VA San Diego Healthcare System and UC San Diego School of Medicine) added, “As we anticipate the USPSTF’s impending guidelines this year, the public should know that the physicians who diagnose and treat women with breast cancer still believe in annual mammography starting at age 40 for average-risk women.”

Results were presented last week at the American Roentgen Ray Society conference in Toronto.

Women with dense breast tissue should consider additional screening such as ultrasound or MRI, according to Nancy Cappello, Ph.D., founder of AreYouDense.org, an advocacy and educational organization working to help women learn about breast density and breast cancer risks. The group has helped to pass breast density inform legislation in 22 states and have introduced or are working on bills in a dozen more.

Emergency doctors and paramedics commonly misinterpret documents for end-of-life care choices

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I wasn’t too surprised to learn that a pair of new studies finds that emergency care providers vary in their understanding of a type of medical order intended to communicate seriously ill patients’ choices for life-sustaining treatments.

Coincidentally, part two of my extensive interview with Nancy Berlinger, Ph.D., a research scholar at The Hastings Center, appears today in Covering Health. Berlinger stressed the need for more conversations and better physician education on end-of-life and palliative care.

The studies show “significant confusion” among emergency physicians and prehospital care providers in interpreting the universal end-of-life care documents, called Physicians Orders for Life Sustaining Treatment (POLST). “Our data suggest that POLST orders can be confusing for Pennsylvania emergency physicians, and likely for physicians nationwide,” concludes lead author Dr. Ferdinando L. Mirarchi of UPMC Hamot, Erie, Pa., and colleagues.

How Well Do Emergency Providers Interpret POLST Documents?

POLST orders are a growing national model for seriously ill patients to document their choices regarding end-of-life-care. The POLST form is a one-page, brightly colored document–varying in color and formatting from state to state–that serves as an active medical order across healthcare settings. The POLST lets patients state their choices regarding resuscitation, either “do not resuscitate” (DNR) or full cardiopulmonary resuscitation (CPR); and other treatments, with options for full treatment, limited treatment, or “comfort measures” only.

Mirarchi and colleagues surveyed Pennsylvania emergency department physicians and prehospital care providers (paramedics and emergency medical technicians) regarding their understanding and interpretation of POLST forms. Both groups were presented with various clinical scenarios of critically ill patients, with POLST forms specifying different options for resuscitation and treatment.

Rates of “consensus”– defined as 95 percent agreement — were assessed in the different situations. Surveys were completed by 223 emergency physicians and 1,069 prehospital care providers.

In the majority of the clinical scenarios, for both emergency physicians and prehospital providers, the results fell well short of consensus benchmarks. “Both studies reveal variable understandings and variable repsonses as far as treating critically ill patients with the available POLST combinations of choices,” Mirarchi commented.

Consensus Reached Only for Patients Choosing CPR and ‘Full Treatment’

Even when the POLST specified “DNR” with “comfort measures” only, ten percent of emergency physicians and 15 percent of prehospital providers indicated they would still perform CPR. The only situation to show 95 percent agreement was when the POLST form specified “CPR” and “full treatment.”

Older and more experienced physicians were less likely to choose “DNR” in certain situations. In both studies, responses were similar for participants with and without previous POLST training.

Intended to address the limitations of “living wills” and advance directives for end-of-life care, “The POLST provides medical orders that are immediately actionable and to be universally honored across various healthcare settings,” according to the study authors.  POLST is currently in use in 20 states; other states are in the process of adopting the standards.  The POLST is generally used by seriously ill patients for whom sudden death within the next year would not be unexpected. However, some states and institutions have adopted its use outside of the specified indications.

According to this Wall Street Journal article, POLST orders may help to ensure that patients receive care consistent with their treatment goals. Additionally, they are very effective at limiting life-saving care and may prevent avoidable readmissions to hospitals.

However, it’s still not clear whether that the POLST combinations truly equate with informed consent by patients. Reports show that the majority of POLST forms are prepared by non-medical personnel, and then become actionable with a physician’s signature.

The new study raises further concern by showing that emergency care providers vary in their interpretation of POLST documents. In some situations, respondents indicate that they would resuscitate when they should be expected to withhold life-saving treatment. Conversely, some respondents would withhold treatment when they would be expected to provide life-saving care.

“Our results reveal clinical and safety issues related to confusion” with POLST documents, the researchers concluded. They call for continued research, standards, and education to help ensure “patient autonomy and appropriate care” regarding life-sustaining treatments for people with serious illnesses and limited life expectancy. They have developed a patient safety checklist to be used at the time of resuscitation to remind providers to confirm and follow expressed treatment choices with an individualized plan of care for the patient.

 

photo credit: Emergency Room via photopin (license)

It’s Heart Health Month

1 and 99.

Two numbers to remember – this month and every month

Heart Disease is the #1 cause of death in the U.S. for both men and women.

99 percent of us need to improve our heart health.

heart-stroke

Take care of your heart. It’s the best Valentine’s present you can give to yourself – and to those who love you.

Check out the American Heart Association’s website for more information on heart disease and stroke – and how you can avoid becoming another statistic.

Many Women with Breast Cancer Have Poor Knowledge About Their Condition

A new analysis finds that many women with breast cancer lack knowledge about their illness, with minority patients less likely than white patients to know and report accurate information about their tumors’ characteristics. This further supports the need to better educate women about their health conditions so they can make more informed treatment decisions.The findings appear in the online version of CANCER, the peer-reviewed journal of the American Cancer Society.

radiotherapy

courtesy Gerry Lauzon CC license

Although previous studies have examined general cancer knowledge, this was the first study that looked at whether women actually know and understand the details about their own cancers. Rachel Freedman, MD, MPH, of the Dana-Farber Cancer Institute in Boston, and her colleagues surveyed 500 women with breast cancer to see how knowledgeable they were about their own cancers, including the tumor stage, grade, and receptor status (breast cancer subtype). While 32 percent to 82 percent reported knowing each of the tumor characteristics that they were asked about, only 20 percent to 58 percent actually reported these characteristics correctly.

Black and Hispanic women were often less likely than white women to know their cancer characteristics, even after adjusting for socioeconomic status and health literacy. 

“Our results illustrate the lack of understanding many patients have about their cancers and have identified a critical need for improved patient education and provider awareness of this issue,” said Freedman in a statement. “Improving patients’ understanding about why a particular treatment is important for her individual situation may lead to more informed decisions and better adherence to treatment.”  Understanding tumor characteristics and the reasons for personalized treatment recommendations could also improve a woman’s trust, confidence, and satisfaction with her cancer treatment providers, Freedman added.

Each year in the United States, more than 200,000 women get breast cancer and more than 40,000 women die from the disease, according to the Centers for Disease Control and Prevention. 

More information about breast cancer can be found through many research and advocacy organizations, including

Don’t Worry, Be Happy. It’s Good for Your Heart.

happyfacePeople who have upbeat outlooks on life are twice as likely to have better cardiovascular health, than those whose outlooks are less rosy, according to a recently published study that looked at links between optimism and heart health.

 “Individuals with the highest levels of optimism have twice the odds of being in ideal cardiovascular health compared to their more pessimistic counterparts,” said lead author Rosalba Hernandez, a professor of social work at the University of Illinois. “This association remains significant, even after adjusting for socio-demographic characteristics and poor mental health.”

Participants’ cardiovascular health was assessed using seven metrics: blood pressure, body mass index, fasting plasma glucose and serum cholesterol levels, dietary intake, physical activity and tobacco use – the same metrics used by the American Heart Association to define heart health. These steps are also targeted by the AHA in its Life’s Simple 7 public awareness campaign.

In accordance with AHA’s heart-health criteria, the researchers allocated 0, 1 or 2 points –representing poor, intermediate and ideal scores, respectively – to more than 5,100 adult participants on each of the seven health metrics. Points were then added up to obtain a total cardiovascular health score. Participants’ total health scores ranged from 0 to 14, a higher total score meant better health.

Participants ranged in age from 45-84. They completed surveys that assessed their mental health, levels of optimism, and physical health, based upon self-reported existence of arthritis, liver and kidney disease. Individuals’ total health scores increased along with their levels of optimism.

Researchers found that the most optimistic people were 50 and 76 percent more likely to have total health scores in the intermediate or ideal ranges, respectively. The association between optimism and cardiovascular health was even stronger when sociodemographic characteristics such as age, race and ethnicity, income and education status were factored in. People who were the most optimistic were twice as likely to have ideal cardiovascular health, and 55 percent more likely to have a total health score in the intermediate range, the researchers found.

Optimists had significantly better blood sugar and total cholesterol levels than their counterparts. They also were more physically active, had healthier body mass indexes and were less likely to smoke. The findings may be of clinical significance, given that a 2013 study indicated that a one-point increase in an individual’s total-health score on the LS7 was associated with an 8 percent reduction in their risk of stroke, Hernandez said.

“At the population level, even this moderate difference in cardiovascular health translates into a significant reduction in death rates,” Hernandez said.

Researchers believe this is the first study that examines the association of optimism and cardiovascular health in a large, ethnically and racially diverse population. Participants for the current study were 38 percent white, 28 percent African-American, 22 percent Hispanic/Latino and 12 percent Chinese. Data for the study were derived from the Multi-Ethnic Study of Atherosclerosis (MESA), an ongoing examination of subclinical cardiovascular disease that includes 6,800 people from six U.S. regions.