Thursday, May 9, 2019

Fear of breast cancer recurrence prompting women to choose prophylactic mastectomy

Assuming that the Mayan calendar mania was wrong and the world spins madly on, today marks the shortest daytime of the year in the northern hemisphere. In Boston, we get just nine hours of daylight; Barrow, Alaska doesn’t get any. Although the winter solstice marks a seasonal turning point, with daylight getting incrementally longer from here until June 21, for people with seasonal affective disorder it’s just another day of feeling lousy.

People with this condition lose steam when the days get shorter and the nights longer. Symptoms of seasonal affective disorder include loss of pleasure and energy, feelings of worthlessness, inability to concentrate, and uncontrollable urges to eat sugar and high-carbohydrate foods. Although they fade with the arrival of spring, seasonal affective disorder can leave you overweight, out of shape, and with strained relationships and employment woes.

We don’t know exactly why seasonal affective disorder occurs. According to a review published in the current issue of American Family Physician, there are probably several different causes, including changes in the body’s natural daily rhythms (circadian rhythms), in the eyes’ sensitivity to light, and in how chemical messengers like serotonin function.

Some people find that taking an antidepressant medication helps. A unique approach is the use of light therapy.
The value of light

If lack of sunlight causes or contributes to seasonal affective disorder, then getting more light may reverse it. Bright light works by stimulating cells in the retina that connect to the hypothalamus, a part of the brain that helps control circadian rhythms. Activating the hypothalamus at a certain time every day can restore a normal circadian rhythm and thus banish seasonal symptoms.

Light therapy entails sitting close to a special “light box” for 30 minutes a day, usually as soon after waking up as possible. These boxes provide 10,000 lux (“lux” is a measure of light intensity). That’s about 100 times brighter than usual indoor lighting; a bright sunny day is 50,000 lux or more. You need to have your eyes open, but don’t look at the light. Many people use the time to read a newspaper, book, or magazine, or catch up on work.

Although light therapy is at least as effective as antidepressant medications for treating seasonal affective disorder, it doesn’t work or isn’t appropriate for everyone. Some people need more light, or brighter light. Others can’t tolerate bright light—in people with bipolar disorder, for example, it can trigger hypomania or mania. And even though the risk of eye damage from bright light is low, anyone with diabetes (which can damage the retina) or pre-existing eye disease should check with a doctor before trying light therapy.

In efforts to make light therapy more effective, researchers are looking to improve it in various ways. One approach is creating light boxes that simulate dawn and sunrise, gradually increasing in intensity from darkness to 300 lux. Another involves using lower intensity blue light, which has a more powerful effect on the retina than white light.
Planning your approach

When I see a patient with seasonal affective disorder, I suggest he or she try light therapy after awakening. If it does not help or it creates bothersome side effects, it may be worth trying antidepressants or one of the light therapy alternatives under investigation.

Although light treatment is relatively safe, here are a few cautions if you want to try it.

    Before investing your money—and time—on bright light therapy, work with a professional who is qualified to make a diagnosis. It’s important to evaluate your individual situation, and to determine whether you really have seasonal affective disorder.
    Buyer beware—the FDA does not test, approve, or regulate light box devices.
    Before buying a light box, ask about the wavelengths of light it delivers (to avoid any that might be harmful, experts recommend fluorescent light without ultraviolet wavelengths).
    Another way to determine whether a product fits the intended purpose is to see if it is used in any hospitals, clinics, or reputable research facilities.

Finally, keep in mind that depression, as well as the symptoms of seasonal affective disorder, can have many causes and that there are many good ways to treat them. Review all your treatment options. Above all, establish a relationship with a professional who can help you periodically review your progress. What happens when the body rejects a protein found in many foods? Ask anyone with celiac disease.

This increasingly common condition—it’s grown four-fold since the 1950s—causes a host of aggravating and potentially disabling symptoms such as gas, bloating, diarrhea, cramps, fatigue, weight loss, and more. But it’s also a trickster, causing subtle changes that may not be identified as stemming from celiac disease.

Take the case of a 22-year-old woman described in today’s New England Journal of Medicine. She ended up in an emergency room after breaking her wrist while playing volleyball. Fix the fracture and send her home? Not so fast. Blood tests showed that she was anemic and had low levels of iron and vitamin D—which were unusual to see in an otherwise healthy woman. A subsequent blood test showed that her body was making antibodies against tissue transglutaminase, a naturally occurring enzyme in our bodies. That’s the hallmark of celiac disease, caused by the body’s harmful reaction to gluten, a protein in wheat, barley, and rye.

“It’s a very useful case to highlight,” says Dr. Ciaran P. Kelly, director of the Celiac Center at Beth Israel Deaconess Medical Center in Boston. “Celiac disease should be one of the first things a doctor thinks about in a person with iron deficiency anemia or chronic diarrhea when there aren’t other likely causes.”
A troublesome protein

People with celiac disease can’t tolerate gluten, not even small amounts. Their bodies mount an immune response to the protein. The inflammation that follows plays out largely in the lining of the small intestine (see illustration below). Damage to the intestinal wall can interfere with the absorption of nutrients from food (like iron), cause a host of symptoms, and may lead to other problems like osteoporosis, infertility, nerve damage, and seizures. (There’s also a related condition called gluten sensitivity—it has similar symptoms as celiac disease but without the intestinal damage.)

Historically, it took an average of 10 years or more from the onset of symptoms to a diagnosis of celiac disease. That’s because the symptoms look like more common problems, such as irritable bowel syndrome. Celiac disease also hasn’t been on many doctors’ radar screens.

That’s changing. Celiac disease is emerging from the shadows, thanks in part to greater attention in the media and the $7 billion market (and advertising) for gluten-free foods. Equally important, a simple blood test for anti-tissue transglutaminase antibodies now makes it relatively easy to tell whether or not a person has celiac disease. A biopsy of the intestine confirms the diagnosis.
Banishing gluten

The treatment for celiac disease—stop eating gluten—sounds simple, but isn’t easy. It means forgoing anything made from wheat, barley, and rye. Even a small amount of the protein can stir up trouble. A University of Maryland study showed that just 50 milligrams (mg) of gluten—a slice of wheat bread contains 2,000 mg—was enough to rev up inflammation and intestinal damage.

“It’s the hidden gluten that can really bedevil people with celiac disease,” says Dr. Kelly, who is also a professor of medicine at Harvard Medical School. That means gluten lurking in foods that shouldn’t have any.

Take soy flour as an example. It shouldn’t contain gluten. But if soybeans are transported in a truck or rail car that had previously held wheat, barley, or rye, or processed in a warehouse or plant that handles these grains, the soybeans and foods made from them can pick up enough gluten to fuel celiac disease.

The FDA is currently working on regulations that will specify the maximum amount of gluten a food can contain and still be considered gluten free. But this won’t do anything about contamination of truly gluten-free foods.
Gluten-free bandwagon

As many as half of people who buy gluten-free products don’t have a clear cut or proven reaction to gluten. Instead, they go gluten free because they think they are sensitive to gluten, or it makes them feel better to avoid it. If you choose to avoid gluten, it’s worth getting checked for celiac disease first for two reasons.

One is that treatment for celiac disease is usually more involved and intensive than treatment for non-celiac gluten sensitivity. The second reason, explains Dr. Kelly, is that if you’ve been off gluten for a while, it becomes very difficult to establish if you do or don’t have celiac disease versus gluten sensitivity. If you suspect you might have celiac, do not eliminate gluten before the tests are completed. Many adult Americans take aspirin every day, often to prevent a heart attack. Headlines about a study published today linking aspirin use with age-related macular degeneration (AMD) may scare some aspirin users to stop, but that’s the wrong message.

In the study, aspirin’s effect on vision was small—far smaller than the lifesaving benefit it offers people with heart. “The benefits of cardioprotection are well established,” says Dr. William Christen, an epidemiologist and associate professor of medicine at Harvard Medical School. “There are too many unanswered questions in this study for it to impact the use of aspirin for cardiovascular disease.”

The study’s lead scientist, Dr. Barbara Klein, agrees. “Coronary heart disease is a killer,” emphasizes Dr. Klein, a professor of ophthalmology at the University of Wisconsin School of Medicine and Public Health. “If you are convinced that people need to be protected from heart disease with aspirin, you wouldn’t stop it because of this potential risk.”
A thief of vision

Macular degeneration occurs when something goes wrong with the macula, a small part of the eye’s light-sensing retina. The macula is responsible for sharp central vision. There are two forms. “Dry” macular degeneration is the most common. It is caused by thinning of the retina. Some people with it have no symptoms and are unaware they have the condition, others have vision loss.

In some people, dry macular degeneration progresses to “wet” macular degeneration. The name reflects the fact that abnormal blood vessels growing in the layers of cells beneath the retina leak fluid and blood, which can injure and scar the retina, causing loss of vision.

For dry macular degeneration, a cocktail of certain vitamins and nutrients can slow or even stop progression to an advanced, vision-robbing form. For the wet form, new drugs can stop or slow the growth of and leakage from abnormal blood vessels.
All eyes on Beaver Dam

As part of the ongoing Beaver Dam Eye Study, Dr. Klein and other researchers have been following nearly 5,000 adults living in the city and township of Beaver Dam, Wisconsin since 1987 to see how their eyesight changes as they age. Participants in the study were checked for signs of macular degeneration every five years. Among other questions, they were asked if they had regularly taken aspirin at least twice a week for at least three months.

In today’s Journal of the American Medical Association, the Wisconsin researchers reported that people in the Beaver Dam study were at slightly greater risk of developing late-stage AMD if they had had been regularly taking aspirin 10 years previously.

“Late stage” means the disease is far enough along to affect vision in one or both eyes. It could mean impaired vision or, eventually, blindness. The study links aspirin particularly to the wet form of AMD.

The added risk associated with aspirin use was small. After adjusting for factors that significantly affect risk for AMD, like smoking and age, 14 in 1,000 aspirin users developed late-stage wet AMD compared to 6 in 1,000 non-users.
Seeing the big picture

Keep in mind that the risk for developing macular degeneration balloons with aging. Should older adults shy away from aspirin?

The answer is no, especially for people who take a low-dose aspirin daily to prevent heart attacks. The small (and still unconfirmed) added risk of AMD is far outweighed by the rock-solid benefits of cardioprotective aspirin. But this study does raise the issue that even a simple, safe medication like aspirin isn’t something you want to be taking unless it will clearly do you some good.

The Beaver Dam study can’t really say for certain if aspirin actually causes late-life vision loss. As in all “observational” studies, researchers can only observe trends and try to link them statistically to plausible explanations—a bit like searching for suspicious-looking characters at the scene of a crime. Scientists try to control for factors that could affect the risk, like smoking and race, it’s hard to be sure what is causing what in the Beaver Dam study.

“They might be at higher risk for developing AMD for precisely the same reasons they are taking aspirin, like cardiovascular disease or an underlying inflammatory condition,” Dr. Christen says. “It’s difficult to disentangle whether this is due to aspirin or underlying risk factors that lead people to use aspirin.”

The American Academy of Ophthalmology recommends that everyone have a baseline comprehensive eye exam at age 40 to check vision, and look for early warning signs of macular degeneration and other eye problems, with follow-up exams as needed. For people 65 and older, the Academy recommends comprehensive exams at least every other year, though people with existing eye conditions might need more frequent follow up. Whether the latest Beaver Dam study will alter the Academy’s recommendations for people who take aspirin remain to be seen. The holiday season gets all the hype at this time of year, but the flu season needs your attention as well. It has come early this year—the earliest since 2003, according to the Centers for Disease Control and Prevention (CDC)—and is expected to be severe. In the last month, new cases of flu in the U.S. have gone from a few hundred a week to more than a thousand a week. Forty-eight states and Puerto Rico have already seen lab-confirmed cases of the virus, and five children have died from it.
Avoiding the flu

Flu is short for influenza, a highly contagious and potentially deadly respiratory disease. Some years the outbreak is relatively mild, other years it is severe. Deaths range from 3,000 a year to nearly 50,000, and about 200,000 people end up in the hospital each year. Symptoms include fever, cough, sore throat, runny or stuffy nose, muscle aches, fatigue, and sometimes vomiting and diarrhea.

The viruses that cause the flu are spread when an infected person coughs or sneezes tiny droplets into the air, and you come into contact with those droplets. You may also become infected if you touch a surface with a flu virus on it and then you touch your mouth or eyes.

It’s easy to bump into an invisible, floating flu virus, or to get some on your hands. So getting vaccinated—and washing your hands often—are your best bets against getting flu. The vaccine isn’t an anti-flu guarantee, but it can reduce your risk by up to 80%.

Most of the flu cases so far this season are the three types included in this year’s flu vaccine: two influenza A viruses (H3N2 and H1NI) and the influenza B virus.
Many avoid the vaccine

So far this year, barely one-third of Americans have been vaccinated against the flu. Why aren’t more people getting a flu shot? Some people worry about the safety of the vaccine. Others say the flu shot makes them sick.

Part of the worry comes from the 1976-77 flu season, when that year’s vaccination was linked to several cases of Guillain-Barre syndrome. This painful nerve disease can cause paralysis, breathing difficulties, and death. A study from Canada published earlier this year in the Journal of the American Medical Association demonstrated a small risk of Guillain-Barre syndrome—about two cases per million doses of vaccine—with vaccination against H1N1 in the 2009 season. The researchers concluded that the benefits of the flu vaccine outweighed the risks.

Does the flu vaccine give you the flu? “Placebo studies show the vaccine doesn’t really cause the flu,” explains Dr. Paul Sax, clinical director of the division of infectious diseases at Brigham and Women’s Hospital and a professor of medicine at Harvard Medical School. “And while all vaccines may rarely cause side effects, the fact that essentially all infectious disease specialists get the vaccine shows that the benefits outweigh the risks.”

In fact, health care workers at a number of Harvard-affiliated hospitals are not only strongly encouraged to get flu shots, but are required to wear masks on the job if they don’t. It’s to protect patients from becoming infected with flu.
Understanding flu vaccines

The flu vaccine can be given by injection (shot) or as a nasal spray.

Nearly everyone can receive the shot, except those who are allergic to eggs or to the vaccine itself. The shot contains inactivated (killed) viruses. If side effects occur, they include fever and aches as well as soreness, redness, or swelling where the shot was given.

The nasal spray contains live, weakened viruses. It is appropriate for anyone between the age of 2 years and 49 years who is healthy and isn’t pregnant. If side effects occur, they include runny nose, nasal congestion or cough, chills, tiredness, weakness, sore throat and headache.

After getting vaccinated, your body develops antibodies that protect you against the viruses included in the vaccine. It takes a few weeks for full protection to develop, and lasts about a year.

Supercharge your cold and flu defenses!

27 surprising secrets, smart strategies, and simple steps to keep your immune system at its cold-and-flu-fighting best
What you can do

Flu season typically peaks in January, February or later, so you still have time to get vaccinated.

Everyone aged 6 months and older is urged to get a flu shot, especially pregnant women, young children, people age 65 and older, and those with chronic medical conditions such as heart, lung, or kidney disease or weakened immune systems. The more people who get the vaccine, the better it is for everyone—even those who haven’t been vaccinated. This is called herd immunity. A Harvard Health video shows how herd immunity works.For many people, retirement is a key reward for decades of daily work—a time to relax, explore, and have fun unburdened by the daily grind. For others, though, retirement is a frustrating period marked by declining health and increasing limitations.

For years, researchers have been trying to figure out whether the act of retiring, or retirement itself, is good for health, bad for it, or neutral.

A new salvo comes from researchers at the Harvard School of Public Health. They looked at rates of heart attack and stroke among men and women in the ongoing U.S. Health and Retirement Study. Among 5,422 individuals in the study, those who had retired were 40% more likely to have had a heart attack or stroke than those who were still working. The increase was more pronounced during the first year after retirement, and leveled off after that.

The results, reported in the journal Social Science & Medicine, are in line with earlier studies that have shown that retirement is associated with a decline in health. But others have shown that retirement is associated with improvements in health, while some have shown it has little effect on health.
Retirement changes things

In their paper, Moon and her colleagues described retirement as a “life course transition involving environmental changes that reshape health behaviors, social interactions, and psychosocial stresses” that also brings shifts in identity and preferences. In other words, moving from work to no work comes with a boatload of other changes. “Our results suggest we may need to look at retirement as a process rather than an event,” said lead study author J. Robin Moon, who is now a senior health policy advisor to New York Mayor Michael Bloomberg.

These changes may be why retirement is ranked 10th on the list of life’s 43 most stressful events. Some people smoothly make the transition into a successful retirement. Others don’t.

For four decades, Dr. George E. Vaillant, professor of psychiatry at Harvard Medical School, and numerous colleagues talked with hundreds of men and women taking part in the Study of Adult Development. Initially focused on early development, the study now encompasses issues of aging, like retirement.

When researchers asked study participants 80 and older what made retirements enjoyable, healthy, and rewarding, four key elements emerged:

Forge a new social network. You don’t just retire from a job—your retire from daily contact with friends and colleagues. Establishing a new social network is good for both mental and physical health.

Play. Activities such as golf, bridge, ballroom dancing, traveling, and more can help you let go a bit while establishing new friendships and reinforcing old ones.

Be creative. Activating your creative side can help keep your brain healthy. Creativity can take many forms, from painting to gardening to teaching a child noun declensions in Latin. Tapping into creativity may also help you discover new parts of yourself.

Keep learning. Like being creative, ongoing learning keeps the mind active and the brain healthy. There are many ways to keep learning, from taking up a new language to starting—or returning to—an instrument you love, or exploring a subject that fascinates you.
Individual effects

Understanding how retirement affects a large group of people is interesting, but doesn’t necessarily have anything to do with how it will affect you.

If you’ve had a stressful, unrewarding, or tiring job, retirement may come as a relief. For you, not working may be associated with better health. People who loved their work and structured their lives around it may see retirement in a different light, especially if they had to retire because of a company age policy.

An individual who has a good relationship with his or her spouse or partner is more likely to do well in retirement than someone with an unhappy home life for whom work often offered an escape hatch.

People with hobbies, passions, volunteer opportunities, and the like generally have little trouble redistributing their “extra” time after they retire. Those who did little beside work may find filling time more of a challenge.

And then there’s health. People who retire because they don’t feel well, or have had a heart attack or stroke, or have been diagnosed with cancer, diabetes, or other chronic condition may not enjoy retirement as much as someone who enters it in the pink of health. Living through the physical and emotional toll of breast cancer is so traumatic that some women can’t bear the thought of doing it again. That’s why a growing number of women who have already been diagnosed with cancer in one breast are taking the drastic measure of having both breasts removed (a procedure called prophylactic mastectomy).

Yet a University of Michigan study presented last week at the American Society of Clinical Oncology’s Quality Care Symposium showed that nearly three-quarters of women who had this procedure were actually at very low risk of developing cancer in the healthy breast. In other words, many women are unnecessarily exposing themselves to the potential risks of a double mastectomy—including pain, infection, and scarring. The researchers concluded that most of the women in their study who chose prophylactic mastectomy didn’t have a good medical reason for doing it and were “not expected to benefit in terms of disease-free survival.”

Clearly these women are making what they feel is the best decision to protect their health. The new study suggests that more and better information about breast cancer recurrence—and the risks and benefits of prophylactic mastectomy—are needed as women consider this procedure.
A growing choice

More and more women are turning to prophylactic mastectomy. A 2010 report in the journal Current Oncology Reports showed that the use of prophylactic mastectomy doubled between 1998 and 2005, and is likely still rising. Fear seems to be one of the main drivers of this increase. In the University of Michigan study, for example, 90% of women who had a preventive double mastectomy said they were “very worried” about their risk of cancer recurrence.

Other possible reasons for the rise in prophylactic mastectomy are more sensitive breast cancer screening methods, which diagnose breast cancer at earlier stages, and improved breast reconstruction techniques. High-visibility celebrities with breast cancer who have chosen to have prophylactic mastectomies are also an influence. “I have a number of people come into my office and ask about how their situation compares to that of Christina Applegate or Giuliana Rancic,” says Dr. Laura Dominici, a breast surgical oncologist at Brigham and Women’s Hospital and assistant professor of surgery at Harvard Medical School. (Allyn Rose, a 24-year-old Miss America contestant, recently announced her plans to have a prophylactic double mastectomy—not because she’s had breast cancer, but because she’s genetically at risk for the disease.)
The real risk

Many women who’ve been diagnosed with breast cancer believe they’ll be safer and spare themselves the stress of future treatment if they have both breasts removed—even if their surgeon isn’t recommending it, says Dr. Judy Garber, director of the Center for Cancer Genetics and Prevention at the Dana Farber Cancer Institute, and professor of medicine at Harvard Medical School.

The average woman diagnosed with cancer in one breast has a less than 1% risk of developing cancer in the second breast. Women are considered at high risk for a second breast cancer—and are therefore what surgeons would consider good candidates for prophylactic mastectomy—only when they test positive for the BRCA1 or BRCA2 gene or another gene that significantly increases breast cancer risk, or they have at least two close relatives (mother, sister, daughter) who have had breast or ovarian cancer.

It’s also important to keep in mind that prophylactic mastectomy won’t guarantee a cancer-free future. “I think it is very important that women understand that, although the procedure reduces risk for future new breast cancers, it has absolutely no impact on their risk of cancer recurrence,” says Dr. Dominici.
Important decision

Women considering prophylactic mastectomy often make this important decision during a very emotional period. “You hope women will take the time to make a good decision and not just have surgery at a time when their fear is the greatest,” Dr. Garber says.

A better strategy may be to delay decision making until after cancer treatment has ended, when a woman may have a different perspective or be in a better frame of mind to make a decision. “Women electing to have both breasts removed when diagnosed with a cancer in one breast need to be sure that they understand the prognosis from their current cancer, as well as their risk of a future cancer,” says Dr. Dominici.

Prophylactic mastectomy isn’t the only way to help prevent breast cancer recurrence. Other options include taking the drug tamoxifen or making lifestyle changes such as exercising and cutting back on alcohol.

“Women shouldn’t feel that having a bilateral mastectomy is going to be the only thing that’s going to save them. It isn’t. There are other ways to approach this,” Dr. Garber says.

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