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Today’s NY Times Article

03/18/2015

I hope I am not inundating you with too many of these “Email Blasts.” However, once again, there is an article on the front page of the NY Times, which I feel mandates some commentary by me. And once again, I have gone back to the original article, which appears in the current issue of JAMA (Journal of the American Medical Association) rather than just the NY Times rendition and summary of it.

The article is entitled “Diagnostic Concordance Among Pathologists Interpreting Breast Biopsy Specimens.” In the first place, you should all feel very comfortable and confident that there was almost 100% concordance for those patients who had actual breast cancer. In other words, this is a relatively straightforward diagnosis and something that is not often misinterpreted by community pathologists. The area where there was less good coordination was in precancerous lesions. I believe this is why it is so important for all pathology specimens to be interpreted by experts.

Certainly, in my area, that of gynecology, I have purposely always used the NYU Laboratory for pathology. These are not only experts but people who train pathologists to go out into the community and perform pathologic evaluations, in general. Some of you have experienced the following scenario, which happens all too often:

• A patient will bring her young daughter in who has had a markedly abnormal Pap smear done elsewhere. She has been told that she needs a LEEP procedure, which is somewhat destructive in that it removes a portion of the cervix.
• This would triple her risk of preterm birth and incompetent cervix when she does decide to have children.
• It is appropriate to do such a procedure for high-grade abnormal Pap smears.
• The first thing I do is request the slides and bring them to the head of GYN Pathology here at NYU and look at them with him over a two-headed microscope. Probably four out of five times over the years that I have done this (and it seems to happen only a couple of times a year), he will end up showing me the area that this other pathologist thought was highly abnormal and is able to downgrade this to mildly abnormal or just atypical, thus allowing the young patient who hasn’t had her children yet to avoid any surgical intervention. Most physicians do not have pathology specimens re-reviewed, especially when these are sent to large commercial labs like Quest or National Health Laboratories. This is especially important if one is going to undertake a serious surgical procedure (like a total mastectomy or a LEEP of the cervix) for a “precancerous” lesion.

The final advice is something I often give to you when I see you in person, which is that your mammography (and therefore, breast biopsies and the pathologists that then look at them) should be done by facilities that are of the highest caliber and quality

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Clarifying Today’s NY Times Article on Menopausal Symptoms

2/17/2015

In today’s NY Times a story on the front page has the headline “Up To 14 Years of Hot Flashes Found in Menopause Study”. I agree totally. In my years of practice I have had many patients, some who resist therapy, and some unable to get off Hormone Replacement Therapy (HRT) who have symptoms even longer than that! I went to the original article published yesterday in the Journal of the American Medical Association (JAMA). This is still another report from a study called SWAN (Study of Women Across the Nation) begun in 1996 with ongoing analysis, this time through 2013. It involved 3302 women. This report was only of women who reported “frequent” hot flashes or night sweats. It was 1449 women, which is 44% of the total. Obviously to them their symptoms are important, but it also underscores the importance of not over ”generalizing”. I have always stressed to all of you that advice, and treatment decisions, must be individualized. It is never “one size fits all.”

 

In addition, in analyzing how long these symptoms persisted, they evaluated only 27% of the total population of SWAN. 28% of the original group had no visits where they reported “frequent” hot flashes or night sweats (recorded in the two weeks prior by an annual questionnaire) and thus were not included in the article. Another 18% of women were not included because they went on HRT because of their symptoms…so we do not know how long symptoms persist in those who DO choose therapy since this paper only included those who DID NOT.

 

Some other random (but hopefully worthwhile comments):

 

-The study confirmed something we already knew: that African American women tend (operative word here is “tend”) to have symptoms longer, then non white Hispanics, then Caucasians, and finally Asians. This is well known and once again may be true of POPULATIONS but may not necessarily apply to INDIVIDUALS.

 

-Other studies have looked at the issue of how long symptoms last and some have reported LONGER and some SHORTER. I often tell patients that by 4-5 years “out” (after menopause, that is the “Final Menstrual Period”), that about 75% of women have little or no symptoms and feel they are quite manageable (unlike the vaginal dryness and atrophy of menopause which gets a little worse the further out one gets). This study was close to that… at 5 years about 65% of women who started at menopause no longer had frequent symptoms and if the symptoms started in perimenopause it was a little more persistent (only 60% were symptom free).

 

-It is important to reiterate that in those patients whose symptoms do start in PERIMENOPAUSE , 1.) pregnancy CAN still occur and 2.) traditional HRT is NOT indicated. If such patients are non-smokers and have normal blood pressure they are excellent candidates for ultra low dose birth control pills. (These are extremely safe, and will actually reduce a number of cancers, but this is another whole topic which I have discussed with many of you.)

 

-Finally, the NY Times article mentions depression being higher in the women with persistent symptoms. Be careful. Is this “which came first: the chicken or the egg?”

They did NOT study women with depression and compare their hot flashes with a control group. If women are not sleeping and their lives are disrupted by symptoms this may well be the CAUSE of more depression and anxiety type symptoms. Or maybe not…

 

I hope this is helpful to you or someone important in your life. Share the information. The most important message though is 1.) don’t believe EVERYTHING you read and 2.) medicine is best administered one patient at a time.

 

Individualization, not generalization is key!

 

As always, yours in health

Dr Goldstein

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TODAY’S NEW YORK TIMES ARTICLE

3/13/2014

Some of you may have seen an article on the front page of the business section of the New York Times today entitled “FDA Panel Recommends Replacement for the Pap Test.” Understand that this is simply an Advisory Committee to the FDA and this recommendation may or may not be adopted by the FDA itself. Furthermore, as pointed out in the article, this does not mean that various societies like the American College of Obstetricians and Gynecologists will automatically change their guidelines. I am compelled to make a few observations: 

  • The article makes reference to the fact that HPV testing is more objective and Pap smear evaluations are subjective. This is in fact true, and one of the main reasons that I send all of your Pap smears to the NYU cytology lab, rather than using large commercial labs like Quest or National Health Laboratories, is that I feel the quality control here at NYU is superior. This is not unlike the comments I made about mammography after the recent article concerning mammograms (which by the way were done in Canada 30 years ago with outdated equipment). Any of these tests are only as good as the people who perform and interpret them.
  • While it is true that a negative HPV test would be somewhat reassuring, the incidence of positive tests is so high, especially in women under 30, that this will lead to a great deal of unnecessary anxiety and intervention with testing. As I have told many of you THEY ARE TURNING HPV INTO THE DISEASE. THE DISEASE IS CERVICAL CANCER.
  • The article correctly points out that the Pap smear has resulted in a huge reduction in deaths from cervical cancer between 1955-1992, but that rate has not declined further. In my opinion that is because 50% of these are related to patients who have never had a Pap smear, another 10% in patients who have an abnormal smear but do not follow up.
  • They quote the number that worldwide 70% of cervical cancers are associated with HPV subtypes 16 and 18, which are the ones this test detects. This data comes from all over the world and relates back to data collected in the mid 1990’s. In the United States, in an article published in 2007, in American women, of all the high risk DNA types of HPV, number 16 and 18 were number 6 and 10 in prevalence. What about all the other high-risk types?
  • The new test, which they are recommending approval of, is made by Roche. Interestingly enough, Roche is the company that makes Gardasil, the vaccine being pushed onto most young women and now even young men by pediatricians. You may recall that a lobbyist for Roche was related to the Governor of Texas and that state came very close to mandating vaccinations for all young girls.

Abandoning Pap smears for HPV DNA testing will result in a flurry of false positives, increase patient anxiety, increase invasive testing and is, in my opinion, not what I would recommend. Good Pap smear screening, with HPV testing where indicated as we currently perform, is in my opinion more than adequate. In more than 25 years of practice, I have had one case of invasive cervical cancer (and that woman walked into my office with the disease).

 

As always, I remain yours in health.

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