bb Albert Provocateur: April 2010

Albert Provocateur

Sunday, April 18, 2010

Screen Saver?

For years now, doctors, nurses, health educators, and patients have sung the praises of screening and subsequent early detection, aggressive therapy, and increased longevity for breast and prostate cancers. They may have gotten it all wrong, however! In fact, recent retrospective studies done at the University of California at San Francisco (UCSF) and the University of Texas Health Science Center in San Antonio, and published in the October 21, 2009 issue of the Journal of the American Medical Association (JAMA), have demonstrated the ineffectiveness of 20 years worth of screening for breast and prostate cancers, which currently account for over 25 percent of annual cancer diagnoses in the United States, in significantly reducing the death rates from those maladies. So, perhaps doctors should refrain from teaching their patients how to perform breast self-exams, until their efficacy can be proven. If that were not all, in November 2009, a federally appointed panel of experts, known as the U.S. Preventive Services Task Force, all but panned baseline mammograms at age 40 in women with neither risk factors nor family history of breast cancer. The rationale behind the task force’s pronouncement from on high was an end not justifying a means, with the risks of mammograms before age 50 outweighing the benefits of early detection of breast cancer. New recommendations, that women aged 50-74 years without symptoms or risk factors of breast cancer undergo mammography every other year, instead of annually, have unleashed a wave of accusations, criticisms, finger-pointing, and protests that the federal government is now rationing health care, to the detriment of its citizens. Nonetheless, evidence continues to mount that screenings are neither savers nor saviors, and even the American Cancer Society (ACS), one of the staunchest supporters of cancer testing, has had to reevaluate its position and scale back support of mass breast and prostate cancer screenings.

The change in position of the ACS and other former supporters of early, regular, and frequent screening stems from the increased detection of small, slow-growing breast tumors that may never cause harm, at the expense of aggressive tumors that arise and grow rapidly between screenings. Were that not all, repeated exposures to screening radiation, false-positive diagnoses of breast cancer, and overtreatment and extensive procedures for slow-growing tumors that may never cause problems place women and their families in the precarious positions of being “damned if they do” and “damned if they don’t.” On the prostate side, controversy is no less evident, with neither the ACS nor the Preventive Services Task Force recommending or justifying routine screening for prostate cancer via prostate-specific antigen (PSA) blood tests, in the face of the most common cancer in men presiding over an increased mortality risk of only 3 percent. So, satisfactory answers are not immediately forthcoming, and each patient must rely on introspection and personal health philosophy to guide judgment on the wisdom and benefits of detecting small, slow-growing, non-aggressive, and/or only remotely lethal tumors, in exchange for peace of mind that may not outweigh the burden of knowledge, the potential complications and drawbacks of overtreatment, and the financial hardships imposed. It makes no sense to inflate unnecessary screenings in these times of shrinking health care dollars.

This medical piece would not be complete, without some final affirmations and a bit of advice to the readers. While regular breast cancer screening is warranted in patients over 50 years of age with no risk factors, it does not mean annual mammograms. Women aged 50-80 with low or average risk may be screened by mammography every other year, with those over 80 perhaps no longer requiring mammograms. Worrisome are the patients who go five or more years without a mammogram, not those screened every one or two years. Self-discovery of a lump or abnormality in a breast, however, no matter how recent the mammogram, mandates immediate visit to a physician.

In the “non-fairer” sex, on the other hand, the jury is still out on routine annual PSA testing to screen for prostate cancer. For every man who avoids prostate cancer, 50 will be treated unnecessarily with subsequent incontinence and impotence resulting, due to a test that fails to distinguish slow-growing cancers that will never cause problems from the aggressive kind.

A screen saver works just fine in the inanimate, but when it comes to the living and breathing, too much of the scientific community’s best of intentions does not always make for a happy ending. In fact, quite the contrary!

ã 2010, Albert M. Balesh, M.D. All rights reserved.

posted by Dr. Al at 4/18/2010 03:19:00 PM | 0 comments

Wednesday, April 07, 2010

The Devil Made Me Do It!

Don’t step on a crack or you’ll have to recite one hundred Our Fathers and Hail Marys, wash your hands ten times or until the skin peels off to prevent contamination, go back five times to make sure you’ve turned off the stove’s gas and locked the front door, and, most importantly, blame the devil for the daily rituals and hell on earth suffered by your psyche in order to guarantee some semblance of a normal life. You’ve got to be kidding, you say. No, if you’re one of the more than three million lost souls in the U.S. wrestling with the anxiety disorder known as obsessive-compulsive disorder (OCD), you know that the description above is not far removed from your quotidian reality. In fact, the series of episodes described might even be a best-case scenario, with severe cases bordering on science fiction or the ludicrous, and veterans of the OCD wars resorting to behaviors and idiosyncrasies that only half a century ago would have landed them in state insane asylums or worse. Victims in some cases, for example, have been known to go for extended periods of months without taking a shower, or the opposite extreme of washing so often that they’ve actually denuded their skin and left little time in the day to do other things, in order to compensate for misgivings, perceived errors, or murmured instructions of sulfurous origins exacting penance for sins as innocuous as touching a doorknob or shaking a hand.
But how does this all start? Where in the world do those recurrent, unwanted thoughts and repetitive or ritualistic behaviors come from? The answers to those questions are not immediately forthcoming, in the wake countless lost hours every day, a great deal of distress, and hurdles thrown in the paths of those who just want to get through a simple day in one piece. Without therapy, medication, and the love and support of those most dear, however, that is as unlikely as putting the square peg of one’s sanity into the round hole of what is generally regarded as normal for the human race.
Frankly speaking, diagnosis of OCD brings some relief. When one realizes that checking a locked door repeatedly to assure its closure is a disease, ever bit as real as heart disease or diabetes, then solutions can be sought for one’s fear of uncleanliness and germs, known as mysophobia, or the utter paralysis brought on by that fear. Those suffering from the ravages of OCD are not alone, and television personalities such as Howie Mandel, afflicted since childhood, have done much to increase awareness and outreach on that score. Destigmatizing OCD, mysophobia, and other mental illnesses, and urging people to get professional help, is nonetheless a full-time job, especially in a society that prides itself on looking good, showing no signs of weakness, and keeping up with the Joneses.
So, just how do we tackle the problem? First, you must realize that there are some definitions to be digested, with obsessions being uncontrollable thoughts associated with various fears, and compulsions being the uncontrollable repetitive actions or attempts to ease anxiety. Enormous periods of time can be lost every day by those afflicted with OCD, as they are drawn onto a merry-go-round or endless loop of obsessive and compulsive behaviors. Fear of contamination, fear of harm or danger, fear of discarding objects, fear of imperfection, and fear of disorder and superstitions are just a few of the obsessions that inundate fragile minds ill-equipped to break the chain. Fear of contamination seeks its champion in repeated handwashing, excessive cleaning, and avoidance behaviors that border on going out of one’s way to bypass the imaginary. When checking a door or gas or electric burner becomes a full-time job, then we know that OCD has won the day. Hoarding behavior, or a fear of discarding objects ranging from newspapers and canned foods to sales receipts and plastic containers, is a sign that all is not well in Oz, and that something bad will happen in the Emerald City if those objects are thrown away. Near and dear to many of us, if not to our teenagers who leave their homework undone, their beds unmade, and their appearance unkempt, is a fear of imperfection that drains hours from our day, as we strive to make the perfect bed, groom ourselves as if to walk the “red carpet,” or print notes, lists, or diaries so impeccably that we leave calluses and blisters on our fingers and a disdain for all that requires transcription of the written or spoken word. In OCD, a perceived failure to be perfect inevitably results in our punishment or catastrophe, and, while we are cognizant of the irrationality of our obsessions and compulsions, we are absolutely powerless to halt their onslaught. If that were not all, order and symmetry, the perfect number, and colors, if not pleasing to the mind, at least tacitly accepted by it, round out our, or perhaps only your, foray into the realm of OCD. How many times have you aligned those cans in your cupboard or those books on your shelf? Once or twice? Ok. More than that? Then perhaps a reality check is in order, as you batten down the hatches and prepare for the OCD storm that is sure to follow.
What can you do when disaster strikes? As always, seek professional help. The weaponry in the armamentarium of the latter ranges from psychotherapy, and, specifically, cognitive behavior therapy (CBT), or retraining thought patterns and routines so that compulsive behaviors to “correct” obsessions are no longer necessary, to medications, with antidepressants that increase serotonin in the brain at the fore. Antidepressants should be prescribed at the lowest possible dosages to control the signs and symptoms of OCD. There are no guarantees, however, and if psychotherapy and drugs don’t work, then the “big guns,” like electroconvulsive therapy (ECT), may need to be called in, to quash an unruly devil.

© 2010, Albert M. Balesh, M.D. All rights reserved.

posted by Dr. Al at 4/07/2010 08:08:00 AM | 0 comments