Monday, September 28, 2009

Behind the (1 in ) eight ball: More breast cancer patients choosing prophylactic mastectomy

The AP wire is reporting that the number of women opting for surgery to remove the healthy breast after a cancer diagnosis in one breast is rising, despite a lack of evidence that the surgery can improve survival. Sometimes this is presented as controversial, but I think this represents rationale behavior by many women choosing this.

There's the powerful slogan that's penetrated popular culture that women have a "1 in 8" risk of breast cancer. That's kind of correct but oversimplifies things. Biology is destiny with breast cancer and appears to overwhelm anything in your diet or the environment in terms of producing breast cancer. Like most cancers, risk of breast cancer increases as you get older. Taking all comers in the United States, a woman's chance of being diagnosed with breast cancer is about 1 in 233 when she's in her 30s which steadly rises to 1 in 8 by the time she's reached 85. However, there are women in that group who are at substancially more or substancially less risk.

Younger patients in particular would seem to benefit the most from prophylactic removal of the breast due to this increasing bias for later tumor development. The survival benefit for this surgery hasn't really been studied (as far as I can tell) in your breast cancer patients out for decades. It's assumed that you'd likely see a significant difference in that groups risk of breast cancer in the post menopausal group. Widely referenced studies (see here) suggest that after prophylactic mastectomy a woman's risk for later developing breast cancer is reduced by an average of 90% (some even suggest closer to 100%).

It's clear to me which way I'd suggest for all but the most favorable tumors in young women. Is it for you?


Saturday, September 26, 2009

UPDATE on teen breast augmentation death: Florida state medical board finds no fault with doctors action

I just saw an update in the Miami Herald (here) on the events surround the anesthesia related death during breast augmentation of Florida teen Stephanie Kuleba, who underwent a fatal malignant hyperthermia(MH)reaction. This is a case I wrote about in Spring 2008 here & here.

Office based anesthesia is common for many procedures including oral surgery, dentistry, colonoscopies, otolaryngology (ENT), and plastic surgery. There's lots of reviews on this demonstrating outcomes and safety data comparable to hospital operating suites. Most plastic surgery procedures in this setting are on healthier patients, which can make a death more shocking.

Writing back then I said,
"I'm not sure what the take home message from this is. It's such a rare event that it's hard to justify having exotic protocols at all times in low risk procedures. Most office surgery suites maintain a supply of Dantrolene, a medicine to treat MH which is almost $2500 per dose and must be restocked often to stay current. There's plenty of adverse events more common then MH, but we don't have aortic balloon pumps or cardiac bypass machines routinely laying around for that. It already sounds like that the family has hired an attorney who is already assuming an aggressive posture in his comments to the media so I'm sure we'll see some legal proceedings even if perfect care for MH was instituted."

Predictably, the teen's parents in this case are still wanting their pound of flesh and have recently decided to proceed with medical malpractice lawsuits against her surgeon and anesthesiologists despite the Florida Department of Health finding there was no evidence of deviation of standards of care in this tragic event. Does that make any sense to anyone?


Sunday, September 13, 2009

On tort reform, President Obama DOES lie

President Obama has spent the week furiously trying to put lipstick on the pig that is his healthcare reform bill. He gave a fine speech last week which was noticeably short (by design) on specifics, and one which left out any plausible way to pay for the program. Trying to defang critics, he generalized a number of areas where centrist Democrats and Republican ideas would be incorporated. One of these was a brief mention of tort reform.

Color me uinmpressed.

As with his summer speech at the American Medical Society (AMA) meeting that was met with boos, the president has over and over made it clear he is not interested in addressing real medical tort reform. If you took the most disingenuous elements of lawyer-speak mixed equal parts with the opacity of politican-speak you end up with the President's message to his Democratic trial bar donors (alongside organized labor, the most influential group in Democratic politics). ie "Relax boys, THERE WILL BE NO REAL RESTRICTIONS ON YOUR ABILITY TO SUE DOCTORS, Amen!"


From the 60 Minutes interview tonight(click here for video)

KROFT: If it came down to getting this plan passed would you be willing to do more in the area of tort reform and malpractice insurance? Would you be willing to agree to caps, for example, on malpractice judgments?

OBAMA: You know what I would be willing to do is to consider any ideas out there that would actually work in terms of reducing costs, improving the quality of patient care. So far the evidence I've seen is that caps will not do that. But there are a range of ideas that are out there, offered by doctors' organizations like the AMA, that I think we can explore.....

KROFT: And the conventional wisdom has been that the reason that the House has always voted against any kind of malpractice reform or tort reform was because of the heavy contributions from the trial lawyers.

OBAMA: That is the conventional wisdom. And I think there's also been philosophical issues and differences about whether or not patients who really have been subject to negligence, whether it's fair to just say to them, "You know what? You can only get a certain amount, no matter how egregious it is."

That is nothing but double-speak goblety-gook which avoid any commitment to do anything. At least Democratic leader Howard Dean had the balls to recently come out and say that tort reform is not going to be in the bill because of the relationship of the party to the trial bar.


Wednesday, September 09, 2009

Buy one (implant), get one free - Stay classy Wisconsin!

A really, really tacky billboard campaign in rural Wisconsin by a wannabe made me immediately think to quote the Will Ferrel character, Ron Burgundy, from the movie "Anchorman",

"Stay classy, Wisconsin!"

Tasteful advertising! Does it surprise anyone that this Doctor promoting plastic surgery is not actually a Plastic Surgeon? Well at least he's a surgeon which is not the case with all these cases. Of note, this yahoo was recently fined (see here) closed to $20,000 for Medicare billing fraud.

Remember to always look for a board-certified Plastic Surgeon when you're considering cosmetic surgery. You can inquire here on the American Board of Plastic Surgery website.


Saturday, September 05, 2009

Breast Reduction Amazon style - the legend of Amazonian breast mutiliation

According to Greek historian, Herodotus, the Amazons were a race of female warriors living on the Thermodon River in Scythia. There were no men in the community, and any boy born was killed or dispatched to his father beyond the river.

Hippocrates wrote that the girls had their right breast burnt off with hot irons such that they might better draw the bow. In the 3rd century AD, Roman historian Justin asserted that the mythological Amazon is derived from the Greek roots a (without) and mazos (breast). In Anabasis of Alexander, mention of the Amazons, said that their right breasts were smaller and were uncovered in battle. This observation could mean the legend of elective mastectomy was really right breast underdevelopment caused by deliberate binding or pinching.

Does it make sense that a mastectomy would make using a bow easier?

Actually it does. It's been observed that most competitive women archers are smaller breasted, and a chest guard is actually worn by many competitors to avoid inadvertent injury to their breast when shooting. The weight of the breast also changes the center of gravity and requires active extension of your lower back muscles to remain erect, a distinct liability for horseback based or hand to hand combat.

Among these legendary Amazonians were Queens Hippolyta, whose girdle Hercules was assigned to recover (sure sounds like a panty raid to me) as one of his 12 great tasks, Penthesilea for whose death Achilles mourned, and Thalestrias who had an affair with Alexander the Great.

In DC Comics, the famous Wonder Woman is supposed to be Diana, daughter of Hippolyta and Amazonian princess. For whatever reason she apparently did not get the memo about having small breast :)

Factoid to store away next time you're a contestant on Jeopardy: Spanish conqueror, Francisco de Orellana named the Amazon River as such after encountering women warriors among the Indian tribes of South America.