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Why Double Mastectomies Are Popular: Watchful Waiting Is Too Difficult?

The rise of prophylactic double mastectomy in women with increased risk of breast cancer has been a topic of recent discussion. In particular, this trend has been observed amongst women with the diagnosis of unilateral carcinoma in situ, or pre-invasive breast cancer. While it has been known that in women with genetic cancer syndromes, including BRCA1 and BRCA2, double mastectomy reduces risk, the efficacy of the approach is uncertain in women with other risk profiles, yet more women and surgeons seem to be doing it.

Knowing when to test, treat and act is part of art of medical practice. The ability to convey this information effectively is also an art. Both patients and doctors may have a hard time embracing watchful waiting with respect to many forms of cancer and pre-cancer. In the case of cancer of the cervix, it is known that infection with human papillomavirus (HPV) is causative in cancer development. However, only a small percentage of those infected actually go on to get cancer. Low grade dysplasia, a condition that is early in the cervical cancer development continuum, frequently spontaneously resolves without treatment. Fortunately, in the case of cervical cancer, there is now a vaccine to prevent high risk HPV infection.

“Watchful waiting” has been most discussed as a treatment strategy for prostate cancer. Treatment for prostate cancer, including radical prostatectomy, is fraught with side effects that may negatively impact quality of life. The watchful waiting approach is most commonly agreed upon for older men with medical co-morbidities, or limited life expectancy. However a recent study in the New England Journal of Medicine followed men who were screened for prostate cancer with PSAs and found no mortality benefit to early detection at 10 years, calling into question the utility of screening even younger men.

In the case of breast cancer, the United States Preventive Services Task Force published its revised guidelines for breast cancer screening in the fall of 2009 suggesting that mammography screening be delayed in most women until age 50. These recommendations were in part based on the finding of “adverse effects” resulting from overzealous screening procedures. Although breast cancer screening in women ages 40 to 50 is known to be effective for early detection, its use is associated with the detection of a range of abnormalities of the breast, which lead to further evaluations including follow-up mammograms, MRIs and biopsies. Of course, these procedures are anxiety-provoking and costly. What’s more, pre-cancerous breast disease, as is true with other precancerous conditions, may not always progress to invasive cancer.

Invasive cancer of the breast arises from pre-invasive conditions of breast tissue, the most benign of which is ductal hyperplasia, followed by atypical ductal or lobular hyperplasia, followed by ductal and lobular carcinoma in situ (DCIS). Even the carcinomas in situ (considered stage 0, cancer) vary in their genetics, histological characteristics and aggressiveness. The differentiation amongst these pre-cancerous conditions may be subtle and subject to variable interpretation depending on the pathologist. The appropriate management of these conditions, once detected, remains controversial.

In the past several decades the diagnosis of pre-malignant breast disorders has grown, paralleling the increased use of screening mammography. DCIS is characterized by many of the same histological and genetic features as invasive breast cancer. In DCIS, however, no invasion through the duct basement membrane occurs. DCIS represents 20% of malignancy detected by mammography. 90% of women in which this condition is detected are asymptomatic at the time of diagnosis. Longitudinal studies of the natural history of DCIS in untreated women suggest that 15 to 60% will develop breast cancer in the affected breast after 10 years. This is a broad range and at this point it is not well-understood what factors cause breast cancer to develop in some women with DCIS, while cancerous changes to regress in others.

DCIS is typically diagnosed after microcalcifications are detected on mammogram by means of stereotactic needle biopsy. The current standard of care involves wider surgical excision of surrounding breast tissue. In 10 to 15% of cases invasive cancer is detected in the excised tissue. However, the impact of DCIS treatment on breast cancer mortality is unclear. In addition, there is no evidence to support the removal of an unaffected breast in cases where the DCIS is unilateral.

With medicine’s current focus on early detection and the abundance of information that it may provide, it becomes increasingly important to make sure that our remedies are not worse than our diseases. After all, as much as we may not like to hear it, we are all diseased, and in effect, pre-cancerous. “First do no harm,” is part of the Hippocratic Oath. It may be easier, and perceived as less risky, to do another test, or to recommend a treatment to a patient in lieu of engaging in a detailed discussion of risks and benefits.

In many cases the risks of pre-cancerous conditions are not well delineated. I am very much in favor of using current medical technology and information to detect cancer and pre-cancer. However in doing this, both doctors and patients must question what will be done with the information that we discover, and develop comfort that watchful waiting can sometimes be a good option when abnormalities are detected.

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.

*This blog post was originally published at ACP Internist*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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