January 4, 2013 | 3:37 pm

Many Women Who Don’t Need Them Are Still Getting Pap Tests

Posted by Albert Fuchs, M.D.

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Cervical cells collected in
Pap tests: normal cells on
the left, precancerous cells
on the right.
Ed Uthman/Wikimedia
Commons

My regular readers know that I frequently bemoan the fact that we have no effective way to test for most cancers, and that in many cancers early diagnosis does not improve survival. Cervical cancer is one of the few exceptions. Since Georgios Papanikolau developed the test named after him, the Pap test has dramatically reduced the incidence and mortality of cervical cancer.

More recent advances have shown that cervical cancer is caused by human papilloma virus (HPV), a sexually transmitted infection. Specific testing for HPV is now frequently performed in addition to the Pap test, and a vaccine against the most dangerous strains of HPV is likely to further decrease cervical cancer incidence.

We also now understand that the changes that HPV cause are detectable years before cervical cancer occurs, so the interval between tests can be quite long. Current recommendations are for all women between the ages of 21 and 65 to have a Pap test every three years. If HPV testing is also used, women over 30 can be safely tested every 5 years.

Women over 65 who have been previously tested and have had normal test results are unlikely to benefit from further testing. Also women who have had a total hysterectomy (surgery in which both the uterus and cervix are removed) do not need further Pap tests, because they don’t have a cervix. (An important exception is women who have had a hysterectomy because of cervical cancer or pre-cancerous changes.)

This week brings us evidence of too much of a good thing. The current issue of Morbidity and Mortality Weekly Report (MMWR) published a survey of women over 65 and women who have had hysterectomies. It asked them if they had a recent Pap test. Two thirds of women over 65 answered affirmatively as did 59% of women who have had hysterectomies. I found that as surprising as if 59% of bald men were still going to their barber regularly. It’s hard to know what’s behind this behavior. These women can’t benefit from the tests they’re undergoing. Perhaps this is a manifestation of long-established habits for both the doctors and the patients. Another possible explanation is that some of the women surveyed are simply wrong. The study didn’t actually check medical records, and some of the women may have thought that they had been tested when they hadn’t. Obviously, the most pernicious possibility is that many doctors are still recommending useless testing to patients who trust them. (If Medicare paid for haircuts one wonders how many bald men would still go to their barbers, just for the attention and social interaction, and how many barbers would sent reminder postcards to their bald patients.)

So if you’re between 30 and 65 and are having both Pap tests and HPV testing and your results have been normal, give yourself 5 years between tests. And if you’re over 65 and your tests have been normal, or you no longer have a cervix, congratulate yourself for permanently escaping cervical cancer and feel free to forego further testing.

Learn more:

Pap Tests For Cervical Cancer Are Often Wasted (Shots, NPR health news)
CDC: Women with hysterectomies getting unneeded Paps (USA Today)
Cervical Cancer Screening Among Women by Hysterectomy Status and Among Women Aged ≥65 Years — United States, 2000–2010 (MMWR)
Announcement: Cervical Cancer Awareness Month — January 2013 (MMWR)
US Preventive Services Task Force recommendations for cervical cancer screening
My post in 2009 summarizing the recommendations for Pap tests: Should You Have a Pap Smear?

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

October 26, 2012 | 1:24 pm

Many Terminally Ill Patients Believe Chemo Might Cure Them

Posted by Albert Fuchs, M.D.

Image credit:
Flikr, Juni A.

Metastatic (stage IV) colon cancer and lung cancer are fatal incurable illnesses. That doesn’t just mean they are life-threatening. A fatal incurable illness is one which has zero survivors. You don’t know anyone who had metastatic colon or lung cancer who survived and is no longer ill.

Chemotherapy is still occasionally used in such cases and sometimes can prolong life by a few months. Chemotherapy might also help temporarily alleviate some of the symptoms caused by the cancer. But what chemotherapy never does in these cases is cure the disease. The distinction is important because chemotherapy itself frequently has serious and uncomfortable side effects and patients who are considering undergoing it should understand the benefits they may gain.

A disturbing study in this week’s issue of The New England Journal of Medicine suggests that many terminally ill patients misunderstand why they are receiving chemotherapy. The study was a survey of over 1,100 patients with a recent diagnosis of stage IV lung or colon cancer who had opted to receive chemotherapy. The survey asked several questions about their expectations of chemotherapy. One such question was “After talking with your doctors about chemotherapy, how likely did you think it was that chemotherapy would cure your cancer?” Response options were “very likely,” “somewhat likely,” “a little likely,” “not at all likely,” and “don't know.”

“Not at all likely” is the only response that conveys an accurate understanding of what chemotherapy can do for these patients. Yet 69% of patients with lung cancer and 81% of colon cancer patients chose one of the first three responses, reflecting mistaken expectations of their treatment. Though previous studies suggested that some patients are mistakenly optimistic in the face of a terrible prognosis, the very high fraction of patients in these studies who apparently believed they might be cured was surprising.

What could account for this? An accompanying editorial ponders the possibilities. Might the oncologists not be giving patients an honest explanation of their prognosis? Prior studies show that most oncologists give bad news honestly, so that is not likely to account for the majority of patients misunderstanding the goals of treatment. Perhaps patients actually know that a cure is impossible and have discussed this with their doctors and their families but are reluctant to share this painful realism with a researcher who is a stranger. Perhaps many patients heard the bad news and chose not to believe it.

Certainly some selection bias is involved. The study, after all, interviewed only patients who chose to undergo chemotherapy. That would include whichever patients were most likely to ignore bad news or exaggerate the possible benefits of treatment. Those who were mostly likely to accept bad news and minimize the possible benefits of treatment were the most likely not to have pursued chemotherapy and would not have been included in the study.

The distressing possibility is that many of the patients surveyed are fooling themselves. In other facets of life self-deception might be beneficial, or at least harmless. (“I look terrific.” “I think I’ll do great in this interview.”) But in this case patients with limited time are choosing to spend that time in healthcare facilities experiencing side effects instead of at home (or on vacation) with loved ones.

One final worrisome finding is that the patients who reported better scores for how well their physician communicated with them were less likely to give accurate responses for the goals of chemotherapy. That means that patients who best understood that chemotherapy could not cure them reported that their physicians were worse communicators than patients who misunderstood their likelihood of cure. Does telling bad news inevitably strain the physician-patient relationship? Do patients bond best with physicians who misinform them with optimism or allow them to misunderstand important aspects of their care?

As patient satisfaction surveys begin to play a larger role in physician compensation we may ironically find that doctors will be increasingly paid to cater to patients’ unstated desire for misinformation.

Learn more:

Many Terminal Cancer Patients Mistakenly Believe A Cure Is Possible (NPR Shots)
Study: We overestimate how much medicine can do (Washington Post, Wonkblog)
Patients' Expectations about Effects of Chemotherapy for Advanced Cancer (New England Journal of Medicine)
Talking with Patients about Dying (New England Journal of Medicine editorial)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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September 14, 2012 | 11:59 am

Ninth hantavirus case linked to Yosemite

Posted by Albert Fuchs, M.D.

Yosemite National Park
Photo credit: CDC

In 1993 in the Four Corners region of the US Southwest a woman developed a cough and progressive shortness of breath and died shortly thereafter. A few days later, her fiancée, a young physically fit man developed similar symptoms was rushed to a hospital and also died. A series of laboratory tests failed to identify any known infectious agent. The Centers for Disease Control and Prevention (CDC) Special Pathogens Branch was notified. Further testing revealed a previously unknown strain of hantavirus. The new strain would eventually be named Sin Nombre hantavirus (perhaps the most paradoxical name I’ve ever encountered).

In Asia and Europe hantavirus infections in people cause a very different illness marked by hemorrhagic fever and kidney failure. This new illness in the US marked by progressive respiratory failure was named Hantavirus Pulmonary Syndrome (HPS). HPS has early symptoms that are very similar to the flu: fever, fatigue, and muscle aches in the thighs and back. About half the patients also experience headaches, chills, nausea, vomiting, and diarrhea. Four to 10 days after the initial symptoms a cough and progressive shortness of breath develop. The lungs fill with fluid. About one third of patients with HPS die.

Since 1993 there have been very few (587) cases of HPS nationwide. The hantavirus strains in the US, like elsewhere, are carried by rodents. Sin Nombre hantavirus is carried mostly by the deer mouse in the western and central US and Canada. People are infected with hantavirus through contact with infected rodents, or their urine and droppings. Hantavirus in the US cannot be transmitted from person to person.

This summer hantavirus claimed the spotlight because of a number of cases linked to Yosemite National Park. Nine visitors to Yosemite have become sick from hantavirus, the most recent this week. Most of them camped in tent cabins in Curry Village in early July. These cabins have since been closed. Three of the nine have died.

The park, along with state and national health agencies, have attempted to contact all campers who have visited Yosemite this summer to advise them to seek care promptly if they develop flu-like symptoms. There is no specific treatment for hantavirus, but prompt admission to intensive care can help support patients on ventilators until the illness resolves. The patients who have survived seem to have recovered completely.

For those of us who haven’t been to Yosemite recently, the CDC advises that the best way to avoid hantavirus is to keep your home and nearby structures (garages, sheds) free of rodents. The links below have some common-sense suggestions.

Our family’s rodent control strategy involves an attractive feline named Pancho. Perhaps we should make her available to the National Park Service.

Finally, with Rosh Hashannah a few days away, I wish my readers a year of prosperity and joy, and no exposures to dangerous untreatable viruses.

Learn more:

Hantavirus in Yosemite: Ninth case reported in another visitor (LA Times)
August 2012 – Yosemite National Park Outbreak Notice (CDC)
Hantavirus (CDC information page)
Tracking a Mystery Disease: The Detailed Story of Hantavirus Pulmonary Syndrome (CDC)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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September 7, 2012 | 10:46 am

Still no evidence that organic food is healthier

Posted by Albert Fuchs, M.D.

Make mine with pesticides. Photo credit: Wikimedia Commons

“It’s not what you don’t know that hurts you, it’s what you know that isn't so.” -- attributed variously to Mark Twain and to Will Rogers

Many popular ideas are popular not because they're right but because of a widespread failure of skepticism. For example, in the 1970s the idea that wide lapels really make you look great was widely adopted without rigorous testing.

Organic food has grown to a $26 billion industry in the last couple of decades largely on public good will. This industry was perfectly poised at the intersection of several of our irrational biases – our fear of “chemicals”, our assumption that natural is better than artificial, and our suspicion of technology that alters living things. Surely our food must be healthier without all those industrial “chemicals”, we told ourselves as we spent sometimes twice as much for organic produce.

My regular readers know that I’ve written previously (links below) that there is no proof whatsoever that organic food is healthier than conventional food. In the current issue of the Annals of Internal Medicine, the question is finally given some rigorous examination.

Since the adjective “organic” is sometimes bandied about carelessly, we should have a general consensus about what it means. Organic plants are grown without synthetic pesticides or fertilizers and are not genetically modified. Organic livestock is raised without growth hormones or routine (i.e. preventive) antibiotics. Organic livestock is fed organically produced feed and is provided access to the outdoors and freedom of movement. Organic food is also generally manufactured without additives or irradiation.

The authors of the paper retrieved every peer-reviewed study that compared either organically and conventionally grown food or the people eating these foods. 240 of these studies were found and their findings were reviewed. The results were strikingly blah, prompting a flurry of media coverage (links below).

The studies found no difference in health outcomes between people eating organic and conventional food. Two studies found higher pesticide levels in the urine of children eating conventional food compared to organic food, but these levels were well below those that cause health problems. There were also no consistent meaningful differences in nutrient levels between the two groups.

I have long been suspicious that organic produce has higher risks for bacterial contamination since the alternative to synthetic fertilizer is fertilizer from animal waste. This also turns out to be unfounded. Bacterial contamination of food was similar in both groups.

There was one small but tantalizing difference. Bacterial contamination of meat was similar in frequency in both farming methods, but bacterial contamination with bacteria resistant to three or more antibiotics was significantly more common in traditionally grown chicken and pork than organically grown animals. That doesn’t prove that the humans who eat that meat are more likely to get sick or that their illnesses would be harder to treat, but it suggests that routine use of antibiotics in livestock has risks which require further study.

There may be lots of other good reasons to buy and eat organic food. Some people think organic food tastes better, and of course that is best left to each one’s palate. Others assert that organic farming practices are better for the environment. But organic farming consumes more resources and uses much more land per food produced, so if most of us ate organic food much more of the environment would be taken up for farming than is currently. There are also ethical reasons to refrain from supporting farming practices that treat animals cruelly. I’m not suggesting that we should not eat organic food, only that we should not do it with the expectation that it is healthier.

So for now, I’ll take my apple with pesticides. Oh, and those lapels are still groovy, no matter what other people say.

Learn more:

Are Organic Foods Safer or Healthier Than Conventional Alternatives?: A Systematic Review (Annals of Internal Medicine)
Why Organic Food May Not Be Healthier For You (NPR Morning Edition)
Study Questions How Much Better Organic Food Is (Associated Press)
Organic food no more nutritious than non-organic, study finds (NBC News)
My previous posts about organic food:

When the Stool Hits the Sprouts
Would You Like Some Salmonella With That?

For a very informative description of the benefits of modern farming, as well as other technical revolutions that make modern life possible, I highly recommend “The Rational Optimist: How Prosperity Evolves” by Matt Ridley.

Tangential Miscellany

Dr. Kevin Pho, the very well known physician blogger and outspoken advocate of social media in medicine, published my post about the coming flood of newly-insured patients. If you didn’t read it when I posted it three weeks ago, you might want to take a look. Check out the comments, too. Many of them are, shall we say, vigorously opposed to my point of view.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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February 4, 2011 | 11:59 am

Benzonatate: A cough suppressant so dangerous, you’d rather just cough

Posted by Albert Fuchs, M.D.

Generic Benzonatate pills. Photo by Derek Kinney

Benzonatate is a cough suppressant available by prescription as a generic medication or under the brand Tessalon. It is chemically related to medicines used as local anesthetics and works by numbing the nerves in the lungs which trigger a cough reflex. It was approved by the FDA in the 1950s.

A recent issue of The Medical Letter briefly highlighted an FDA warning about benzonatate. (Links to The Medical Letter review and the FDA warning are below.)

The FDA warning focused on accidental overdose in children under 10. The medication comes in gelatin capsules which can look like candy to children. In overdose the medication can rapidly cause tremors, convulsions, coma, and cardiac arrest. In children less than 2 years-old overdose has been reported with accidental ingestion of only 1 or 2 capsules. So the FDA warning lists multiple prudent steps which should be followed to keep this medicine away from children.

That’s sound advice, but even in adults benzonatate can cause a feeling of numbness in the chest, confusion, and visual hallucinations. I’m certainly sympathetic to the miserable patient with a cold or bronchitis who has a terrible cough. Coughing can be very disruptive to work and to sleep, and patients can be desperate for relief. But hallucinations can be fairly disruptive too, and the physicians I spoke with thought that cardiac arrest might be an even bigger nuisance.

The Medical Letter authors conclude “when a cough suppressant is truly necessary, dextromethorphan or even codeine might be a safer choice.” When codeine compares favorably in safety to another medicine, it might be time to reconsider why we ever use it.

Learn more:

FDA Drug Safety Communication: Death resulting from overdose after accidental ingestion of Tessalon (benzonatate) by children under 10 years of age

The Medical Letter brief: Benzonatate Warning

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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