Friday, June 27, 2008

Is Canada's health system overdue for an "Extreme Makeover"?

I've pointed out here on Plastic Surgery 101 that despite the dysfunction of the American health care system, the alternatives in other western nations have their own problems. In 2007 I posed the question "So You Think You Want Universal Health care?" and featured Dr. Val's review of "Sicko" which glowingly featured other countries' systems.

It was particularly interesting to me to see the "religious conversion" of one Claude Castonguay on this topic. Who is Claude Castonguay? He's the father of Canada's socialized medicine program. After four decades, he finally admitting that the system he laid out for Canada is failing to meet both the medical needs of beneficiaries as well as the budget needs of the individual Canadian provinces. Castonguay now advocates contracting out services to the private sector and American-style co-pays for patients who want to see physicians.

For an interesting overview on this, read the Investor's Business Daily editorial page article "Canadian Health Care We So Envy Lies In Ruins, Its Architect Admits". The Canadian author, David Gratzer, has written extensively on Canada's uneasy relationship with their countries health program.


Saturday, June 21, 2008

Dr. Zenn flamed in Freakonomics plastic surgery Q & A session

Little did Duke University plastic surgeon, Dr. Michael Zenn, know what he was in for in a recent Q&A guest appearance in the Freakonomics Blog column in the New York Times. Out of about 20 questions on a range of subjects he responded to, he made the "mistake" of accurately discussing a single innocuous question about breast implants.
Q: Would you endorse cohesive gel instead of silicone due to the concern over safety issues of silicone? Or do you believe that was all just hoopla? Is it true that breast implants should be redone every 5 to 10 years?

A: Today’s breast implant options are saline or silicone. Saline implants are a silicone shell filled with salt water, silicone implants are a silicone shell filled with cohesive gel. Both implants are equally safe, both have the same safety profile.
The Institute of Medicine found that much of the concerns were hoopla — except for the problems that they both have: rupture, scarring, and infection. Most plastic surgeons and patients will tell you silicone just feels better. Implants are replaced when one of the above problems occurs

Skip down to the comments section and you'd think he was advocating beating your wife as nearly 5 out of every 6 comments are by breast implant "survivors" wailing alternately on his intelligence, character, and ethics. Ah, the wonders of the Internet to organize like-minded partisans into rapid response teams!

Much like the autism vaccine conspiracy theorists, the breast implant siliconistas come off looking out of touch with such reflexive outrage on command, particularly when you recognize the kind of heavy duty microsurgical and reconstructive surgery practice that Dr. Zenn is known for at Duke. He's one of the good guys for Pete's sake!

There's intelligent reasons to object to breast augmentation surgery, but claiming it caused symptom or disease "X,Y,Z...." is a dead horse that's been buried several times over! For a refresher see here and here to recap the comprehensive 2007 landmark review.


Monday, June 16, 2008

Follow up to a question on breast cancer

I got a question about some of the ideas I was talking about in my last post on how I think about breast cancer. A breast cancer patient wrote me and asked about the difference in how her oncologist explains things
"They quote an 80% recurrence free 10 year survival rate for stage IIA and 75% for stage IIB. I'm stage IIA and my onc says I am probably cured (after surgery, chemo, etc.).

Do you really think all node positive younger women are destined to recur?

Another question: how do you compare positive nodes with lympho vascular invasion? My onc says that there is no data that LVI is as negative an indicator as nodes."

I think it's important to understand that not all breast cancers of stage "x" are created equal, and the biologic "aggressiveness" of a tumor can really skew your personal risks. I talked about 3 of the more important factors (node status, estrogen receptor status, and tumor size), but you've also got histologic characteristics (like tumor grade) and other genetic markers (like HER2/neu) in the mix. Some % of these patients also identified or unidentified inherited genes or mutations which increase their risk substantially for breast and other cancers.

There were two competing worldviews of breast cancer in the classic "Halsted Model" (breast cancer progresses from local->regional->systemic disease) and the "Systemic Model" (breast cancer is already systemic at the time of most diagnosis). I found a nice summary of these ideas on this old newsgroup post for those interested. Personally, I split the difference in my head in that I think that if you're node negative with favorable histology the Halsted model is still true, and that a true absence of residual cancer is possible. If you have nodes involved I'm inclined to believe the Systemic Model in that you have already likely have had some cancer burden establish elsewhere. This is supported by the fact that metastatic breast cancers still show up decades after mastectomy on occasion with no local or regional recurrence of the original cancer preceding it.

Younger breast cancer patients are particularly worrisome in that you have some many decades left of potential exposure for recurrence or new primary breast cancers. It makes absolutely no sense to me to push breast conservation (lumpectomy and radiation) for all but the most favorable invasive cancers in women in their 20's or early 30's. I think maximum risk reduction should be advised for many of these women with bilateral prophylactic mastectomy.

For stage II/III breast cancers (those without systemic mets) the data's a pretty slippery slope where 10 year survival curves run from 70-78% in the more favorable patients to 20-40% depending on grade, size, and # of nodes. This data is laid out nicely at this British Cancer site. Keep in mind that all 3 of those factors are subject to sampling error, and that some of the stage II patients are actually stage III.

There's a great article in the Atlantic magazine "Good News and Bad News About Breast Cancer" from a decade ago which is much more eloquent then I am trying to be reluctant about telling people they're "cured" from breast cancer. It features some of the work by one of my professors, the late Dr. John Spratt from the University of Louisville, who was really visionary in describing tumor's behavior and growth clinically

Breast cancer, unfortunately, is not among this select group (of tumors we can eradicate). As far as we know, a woman found to have invasive breast cancer is always at higher risk of dying prematurely than women without breast cancer. Even thirty years after her diagnosis she is up to sixteen times as likely to die of the disease as a woman in the general population. That is why responsible researchers in this field avoid the word "cure." Even as they report advances, they must acknowledge the reality: Postsurgical chemotherapy and antihormonal therapy do buy time—an important advance. The slowed progress of the disease can give a woman additional years of life and even allow her to die of other, less traumatic, causes. But breast cancer is every bit as incurable as it was in Halsted's day.


Saturday, June 14, 2008

Breast Cancer primer and a new wrinkle in breast cancer treatment

There was a good article for the lay public a week ago in the New York Times "With a Tiny Bit of Cancer, Debate on How to Proceed" about the phenomena and controversy over breast cancer "micrometastasis" to lymph nodes. I do a lot of breast cancer related surgery and have this kind of discussion frequently with patients. I've tried over the years to come up with simple concepts for these women who often feel overwhelmed with ideas and terms that have been poorly explained to them.

If you're trying to keep things simple for patients with invasive breast cancer (meaning it has acquired characteristics on microscopic exam suggesting it has the potential to spread elsewhere), it's important to come up with a simple way to explain what their diagnosis really means. There's 3 things that really affect whether or not you're likely to do well when you're diagnosed with invasive breast cancer.

  1. the size of your tumor

  2. the presence or absence of cancer in your lymph nodes

  3. the presence of Estrogen hormone receptors on the cancer cells

Tumor size and nodal status are proxies for metastatic potential. A larger tumor is more likely to have spread to the lymph nodes at the time of diagnosis. A tumor present in the lymph nodes is in turn more likely to have spread elsewhere and show up again down the road as systemic terminal disease. Breast cancer, like most solid tumors that spread via lymphatic tissue, is conceptually really only "cured" if you remove it surgically before it gets to lymph nodes. This basic fact is essentially unchanged despite steady refinement in radiation (XRT) and chemotherapy (CRT) treatments for 60 years. XRT or CRT do not cure anything, but rather decrease/delay recurrence or palliate symptoms. (I'm simplifying this greatly, but that's the skinny in a nutshell).

Estrogen receptors (ER) are conceptually an "on/off" switch for normal breast tissue cells. A breast cancer cell that still maintains this normal regulatory switch offers a target for hormone manipulation. This "killswitch" provides the basis for medicines like Tamoxifen or Arimidex to show improvements in local recurrence after surgery by blocking these receptors or interrupting estrogen metabolism by essentially "starving" the tumor. We're increasingly seeing how important having this receptor is, particularly in post-menopausal women. It's looking more and more from tumor databases that many older women with ER+ tumors may be able to avoid chemotherapy altogether after surgery, and this observation is currently being tested in prospective trials. A breast cancer that's ER- (missing the receptor) suggests a more "primitive" tumor that's lost some of it's normal regulatory mechanisms and implies a worse prognosis. I found a really nice primer on this for people over at "Cancer Geeks"

Complicating treatment options now is our increasing ability to detect infinitesimal amounts of cancer cells (micrometastasis) in some lymph nodes that would have been labeled normal just a few years ago. Do we treat this the way we traditionally did positive nodes or are we over treating? We just don't know. It has played a little havoc with interpreting some breast cancer data that was suggesting we were doing better with our treatment.

Why? Well if you suddenly take these micromet positive patients and up the stage of their diagnosis like you would normally with positive nodes, you make both the node - and node + groups look like things are getting better. Nothings really changed except you're removing people who do worse from one group and putting them into a group of node + cancer patients where they will do better then their peers. (I cannot for the life of me think of the name for this statistical phenomena....)

Anyway, read the article (click here) as it's interesting.



Tuesday, June 10, 2008

Conan the Barbarian's wants his breasts back.

Computer game publisher Funcom had to do some fixing of their popular online mulitplayer game when apparently a recent update of the game's software code left the female characters suddenly "breast deficient".

The MMORPG Age of Conan: Hyborian Adventures features partially nude female character models. Based on the original stories by Robert E. Howard and brought to the big screen in 1982 by Gov. Arnold Schwarzenegger, the game takes place in the fantasy world of Hyboria, which combines fantasy elements with strong sexuality.

This issue has caused controversy all over nerd-dom with hundreds of messages left by players demanding Funcom bring their boobs back. Seen below is a pair of images whose player felt like they'd had a mastectomy.

"Funcom can confirm that some of the female models in the game have had the size of their breasts changed. This is due to an unintended change in data that was introduced in an earlier patch, data which controls the so-called morph values associated with character models and the size of their respective body parts. We are working on a fix for this and your breasts should be back to normal soon. The plastic surgeons of Hyboria apologize for the inconvenience."

Well at least they have a sense of humor about it!


Sunday, June 08, 2008

Beverly Hills Rhinoplasty Blog

I'd like to direct some traffic to the really good Beverly Hills Rhinoplasty Blog. Excellent original and insightful articles without the up front promotion that plagues many Plastic Surgery/Cosmetic Surgery blogs run by surgeons.
I've enjoyed their particular focused writing on rhinoplasty and facial aging!


Friday, June 06, 2008

Something else that belongs on bull#%@*.com

I was pleased (snark!) to find out via the mail today that I am now officially one of "America's Top Surgeons" as recognized by the "Consumers' Research Council of America" (CRCA). Ever heard of it? Me neither.

What do you have to do to be recognized? Have a medical licence and a credit card to buy their over-priced cheezy swag plaques and knick-knacks to impress patients with as far as I can tell.

The sad thing is that some meaningless promotional thing like this is just as likely to get someone's attention for my skill as any of my academic awards, real diplomas, or multiple board-certification certificates.


Tuesday, June 03, 2008

www.bull#%@*.com - the wild,wild world of hospital rankings

US News and World Reports' (USNWR) annual hospital ranking, akin to their notorious college rankings, is kind of the king of the block for these types of rankings. Keep in mind though, there are hospitals on some of those lists that patients in some of those cities (and even some doctors who work in those hospitals) won't take their dog to, particularly in some urban teaching hospitals. (And No, I'm not naming names!)

The "leapfrog study" indexed by USNWR for rankings reviewed available data from nearly 1300 hospitals and ranked hospitals largely (as I understand it)on 4 endpoints

1. Having intensive care units staffed by specially trained doctors

2. Having computerized order-entry systems for medications and other orders with error-prevention measures

3. Performing procedures such as cardiac catheterization and caring for certain high-risk neonatal conditions

4. Having practices such as those designed to control hospital-related infections and cut down on medication and treatment errors.

It's hard to argue in theory that these are bad goals, but are these the things that patients need/want and is the information we're using to assess it accurate. A number of high profile institutions are typically included on these list which can make some doctors chuckle.

I saw an interesting editorial in the journal, Contemporary Surgery,a commentary on how confusing or misleading it is to try and figure out which hospitals, programs, or physicians are "the best". A quick review of a number of consumer oriented web sites provide significant inconsistencies -- for example, with colon resections for cancer, one hospital was ranked best by two sites but worst by the other site, and the hospital ranked best on that site was ranked worst on another, in a study reported in the journal, Archives of Surgery. Why is this so? There is no standard way of calculating quality differences, thus different sources (despite good intentions)come up with different results for the same hospitals

"What makes the 2007 Toyota Camry Motor Trend’s Car of the Year? Who decides who should be ranked number 1 in college football? Which tastes better: Coke or Pepsi? More importantly, is your hospital any good, and are you any good?...Ask patients to weigh in on their surgical experience or hospital care and you might be surprised to find out what they want (free parking). Or, what they don’t care about (board certification)."

Sites like Healthgrade, purport to offer patients some objective criteria for making comparisons between hospitals. This site ranks hospitals, surgery centers, and nursing homes based on data generated from Medicare records. Hospital rankings are based on 13 AHRQ (Agency for Healthcare Research and Quality) categories that include: decubitus ulcers, death in low mortality DRGs, postoperative hip fracture, and postoperative PE or DVT among others. The rankings are “calculated” by 100 employees in Golden, CO, using Medicare data that hospitals supply. Repeat: your very own hospital supplies the data!

If you want to get an even more confusing way to look at healthcare, you can also check out a site like which purports to give consumers (err......) patients comparisons for the cost of surgical procedures. As most of those numbers represent "funny money" (ie. neither the feds, hospitals, nor insurers expect to pay these imaginary numbers).


Sunday, June 01, 2008

Malignant Hyperthermia confirmed in Florida Plastic Surgery death

An autopsy has confirmed that the South Florida teenager, Stephanie Kuleba, who died this Spring after corrective breast surgery (reportedly for significant asymmetry and inverted nipples) suffered from a rare genetic disease that had been speculated to have causes her death. Genetic testing at the University of Pittsburgh shows she possessed the genetic mutation RYR-1 which is responsible for most cases of the malignant hyperthermia (MH) response to certain inhaled anesthetics. However, over 80 genetic defects have now been potentially associated with MH. As these mutations are inheritable, they will vary in rates among the population and some increased clusters of MH mutation carriers have been suggested in states like Wisconsin, Nebraska, West Virginia and Michigan.

The exact incidence of Malignant hyperthermia is unknown, but the rate of occurrence has been estimated to be as frequent as one in 10,000 or as rare as one in 100,000 patients who undergo general anesthesia. (A range that big suggests they have no idea to me) There is no practical screening test to determine if a patient has the rare condition so you rely on family history or consultation questions to identify high risk patients. Again, the incidence is so rare there is no way to prevent these MH events from happening. The signs that develop are usually suble (ie. a tense jaw) before they're not (ie. 104 degree temp and cadiovasular collapse).

Despite her doctors efforts to treat the Ms. Kuleba during the event with the medication Dantrolene, her parents claim her Plastic Surgeon's office was not prepared to care for their daughter once they had figured out that she was suffering from the hidden hereditary condition and have (in the great American tradition) announced their intention to file a lawsuit.

When MH is identified or suspected, time becomes valuable for salvage treatment. As soon as the malignant hyperthermia reaction is recognized, all anesthetic agents are discontinued and the administration of 100% oxygen is recommended. Dantrolene should be administered by continuous rapid IV "push" beginning at a minimum dose of 1 mg/kg, and continuing until symptoms resolve or the maximum cumulative dose of 10 mg/kg has been reached.

Kulebas' family attorney Roberto Stanziale, has said the teenager should have received as many as seven vials of the drug as an initial dose. On medical records Stanziale obtained following her death, one doctor noted she received one vial of the antidote. The other doctor wrote she received two. It's not known at what time the drug was administered or whether there was enough Dantrolene available at Dr. Schuster's Boca Raton clinic, Schuster Plastic Surgery. Both doctors have defended their actions, saying the situation was handled appropriately and that Kuleba received the Dantrolene dose needed once they consulted with the Malignant Hyperthermia Association (MHA) hotline and called an expert at the Mayo Clinic in Minnesota.

This dosing issue and it's timing is going to be a big issue in the lawsuit. You can't really give informed consent for MH as it's so rare so that shouldn't be an issue (although that will likely be claimed by a plaintiff's attorney). According to the brochure for Dantrolene, each vial contains 20 mg of the drug. As it's suggested in her anesthesiologists notes, she received 2 vials initially (40mg) while they called the MHA hotline to confirm treatment (as again it's so rare no one really has a lot of experience with treating it). That 40mg dose is in the ballpark for the recommended range (by weight) for initial treatment for most thin teenagers.

At the end of the day, I'm not sure what's going to be achieved with this lawsuit. It sure seems like reasonable steps were initiated by her doctors after the event to try and save this girls life. There is only so much you can do when unforeseen or extremely rare complications arise and no amount of preparation can prevent some bad outcomes. Contrast the hostile posture of the Kuleba family attorney with this MH tragic event during orthopedic surgery on a 20 year old described by Dr. Henry Rosenberg, President of the Malignant Hyperthermia Association of the United States. The pain of the medical staff and their communion with the deceased's family is moving.

I hope that this event will continue to foster more discussion on oversight for office-based surgery and anesthesia. It's ironic that it's actually been Plastic Surgery that been the most progressive in regulatory oversite in ambulatory surgery. While this case was an anesthesia complication rather then a surgical one, the who's, where's , and how's of who can (or should) be doing surgery is overdue for more scrutiny.