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Questioning Ovarian Cancer: Why Such A High Fatality Rate?

Photo Credit: Wikimedia Commons

Photo Credit: Wikimedia Commons

There is tragic news coming from the entertainment world today.  Pierce Brosnan announced that his daughter, Charlotte, age 41, died of ovarian cancer three days ago.  This is the same illness that took her mother’s life in 1991 when she, like her daughter, was in her early 40s.

Angelina Jolie – who underwent a preventative double mastectomy earlier this year —  lost her mother to ovarian cancer in 2007.

According to the CDC, ovarian cancer is the second most common gynecological cancer, after uterine cancer, and it’s the cause of more deaths than any other gynecological cancer.

The numbers look like this: ovarian cancer kills 15,000 women and approximately 22,000 new cases are diagnosed annually in the US.  Approximately 90% of cases occur in women over 40 and the majority of diagnoses are given to women aged 60 years or older.   According the the American Cancer society, the survival rate for patients who live for five years after they are diagnosed with ovarian cancer is 44%.

Unlike breast or cervical cancer, there is no reliable screening measure for ovarian cancer.  Once it is detected, the first line treatment option is surgery.

Earlier this year, The New York Times reported on a study that suggested the high fatality rate amongst ovarian cancer patients is attributable to widespread deficiencies in the typical treatment most women receive. The article reports that only a third of women with ovarian cancer receive “best practice” treatment, which the study says, is a complicated and intensive operation performed by a highly specialized surgeon.

Here is an excerpt from the article:

Cancer specialists around the country say the main reason for the poor care is that most women are treated by doctors and hospitals that see few cases of the disease and lack expertise in the complex surgery and chemotherapy that can prolong life.

If we could just make sure that women get to the people who are trained to take care of them, the impact would be much greater than that of any new chemotherapy drug or biological agent,” Continue reading

Study: Common Surgery For Prolapse Fails Nearly 1 Out of 3 Women

We’ve written a lot about the scary complications associated with vaginal mesh, synthetic devices that are surgically implanted to treat women suffering from prolapse. This condition, which afflicts millions of women after childbirth or as they age, occurs when stretched or weakened pelvic-area tissues give way, allowing the bladder or other organs to sag or bulge into the vagina.

Now, adding to the mounting data on the potential risks of prolapse surgery in general, a new study in the Journal of the American Medical Association finds that a common surgical treatment for prolapse — one considered the “gold standard” involving abdominal surgery — fails nearly 1 out of 3 women.

So why does prolapse surgery matter? As the JAMA study authors note, nearly 1 in 4 woman have at least one pelvic floor condition and “more than 225,000 surgeries are performed annually in the United States for pelvic organ prolapse.” So, any woman considering this surgery should be aware of the “long-term risks of mesh or suture erosion.” Continue reading

Angelina Jolie’s Double Mastectomy: How Times Have Changed

(Alastair Grant/AP)

(Alastair Grant/AP)

About five years ago a close friend of mine had a prophylactic double mastectomy to lower her extremely high genetic risk of developing breast cancer, which had killed her mother. She begged me to keep the operations a secret: she didn’t want to worry her two young daughters.

Today, in a New York Times opinion piece that is about as out-there and open as it gets, 37-year-old actress and activist Angelina Jolie, who carries the BRCA1 gene which greatly elevates her risk of breast and ovarian cancer, writes that she recently had her breasts surgically removed to lower that risk.

On April 27, I finished the three months of medical procedures that the mastectomies involved. During that time I have been able to keep this private and to carry on with my work.

But I am writing about it now because I hope that other women can benefit from my experience. Cancer is still a word that strikes fear into people’s hearts, producing a deep sense of powerlessness. But today it is possible to find out through a blood test whether you are highly susceptible to breast and ovarian cancer, and then take action.

My own process began on Feb. 2 with a procedure known as a “nipple delay,” which rules out disease in the breast ducts behind the nipple and draws extra blood flow to the area. This causes some pain and a lot of bruising, but it increases the chance of saving the nipple.

Two weeks later I had the major surgery, where the breast tissue is removed and temporary fillers are put in place. The operation can take eight hours. You wake up with drain tubes and expanders in your breasts. It does feel like a scene out of a science-fiction film. But days after surgery you can be back to a normal life.

Nine weeks later, the final surgery is completed with the reconstruction of the breasts with an implant. There have been many advances in this procedure in the last few years, and the results can be beautiful.

I wanted to write this to tell other women that the decision to have a mastectomy was not easy. But it is one I am very happy that I made. My chances of developing breast cancer have dropped from 87 percent to under 5 percent. I can tell my children that they don’t need to fear they will lose me to breast cancer.

Jolie’s mother died of cancer at age 56 and Jolie writes that she didn’t want to put her own kids through that kind of pain if possible. That this highly public figure offers such intimate details about her body and her breasts may be a sign that the taboos around cancer are dwindling. (“On a personal note,” Jolie writes, “I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity.”)

Sharon Bober, a clinical psychologist and director of the Dana-Farber Cancer Institute’s Sexual Health Program, who counsels many women who have had similar surgeries, said in an email that Jolie’s honesty is truly refreshing:

Wow!

One thing that strikes me is how times have changed – not that many years ago BRCA carriers would be worried about insurance being dropped, stigma, judgement, (“you are removing healthy breasts?? What are you crazy??”) and now this too is out of the closet. Continue reading

Globe: Whopping $7M Settlement In Gender Bias Suit Against Hospital, Surgery Chief

Part of Beth Israel Deaconess Medical Center

Part of Beth Israel Deaconess Medical Center

The Boston Globe’s Liz Kowalczyk reports here:

In a striking settlement of a high-profile case, a Harvard doctor who said she endured years of sexist treatment at Beth Israel Deaconess Medical Center will collect $7 million — and will have the hospital’s pain clinic named in her ­honor.

Employment lawyers said the hospital’s settlement with Dr. Carol Warfield, its former chief of anesthesia, appears to be one of the largest for a gender discrimination case in Massachusetts. Ilene Sunshine, a lawyer who represents defendants in bias suits, said it seems “enormous,’’ though she pointed out that it is hard to compare because settlements usually remain confidential.

The agreement — in which the hospital and other defendants did not admit doing anything wrong — closes an embar­rassing stretch in the ­Harvard teaching hospital’s ­illustrious history.

Warfield, who became chief of anesthesia in 2000, said Dr. Josef Fischer, former surgery chief, discriminated against her because she is a woman, openly ignoring her in meetings and lobbying for her ­removal from her job. When she complained to Paul Levy, then chief executive, she ­alleged, both men retaliated against her and forced her out.

Readers, is this an anomaly or does it reflect significant cultural change? Surgeons have such a reputation as the arrogant cowboys of any hospital staff; is that truly changing? Does this suit send the message that it must? Read the full Globe story here.

Beds, Socks, Time-Outs: Such Simple Ways To Avoid Hospital Harm

Big hospitals can seem like impossibly complex organisms, but how simple some of these patient-safety improvements are! From Beth Israel Deaconess Medical Center:

BOSTON – Reducing preventable harm in hospitals often starts with small, low-tech steps: brushing the teeth of patients on ventilators; using low-rise beds and socks with safety treads on both sides; completing a surgical time out before mounting a blade on a scalpel.

Those small steps have yielded big results at Beth Israel Deaconess Medical Center – from a 90 percent reduction in ventilator-associated pneumonia since 2006, to progress in reducing patient falls with injury and in helping to avoid wrong site surgeries. They are some of the key lessons learned and implemented after the hospital declared the then “audacious goal” to eliminate preventable patient harm by 2012.

Those safety steps may seem obvious now, but of course, hindsight is always easy. Yes, “after the fact, it seems obvious,” said Dr. Kenneth Sands, the hospital’s senior vice president for health care quality, but “you need to have that ‘Aha’ moment.” Consider luggage, he said; he spent years lugging around bags because no one had thought to put wheels on them. “The good news is that some of these things are very simple and not technological,” he said, “but they are sometimes only obvious in retrospect.”

More from the hospital:

BIDMC has posted a video on its public website that chronicle three stories that represent how the issue is being addressed:

Preventing ventilator-associated pneumonia
Ventilator-associated pneumonia is a problem that can affect between 10 to 20 percent of intensive care patients who need assistance breathing. Bacteria can collect in the breathing tube and work its way into a patient’s lung and contracting VAP can double a patient’s risk of dying. Continue reading

Must-Read: The Tale Of A Surgery Gone Very, Very Bad

(Martin. Boyer/flickr)

The first hint that this story will not end well comes early, as writer Kerry O’Connell considers surgery for his dislocated left elbow and fractured forearm sustained after falling off a ladder in his driveway in Golden, Colorado.

In the current issue of Health Affairs, he writes:

…the surgeon said that in lieu of a plaster cast, which wouldn’t provide the flexibility my arm needed, he’d bolt a metal hinge device called an external fixator onto the outside of my arm. It would be held in place by three-inch bolts screwed through my arm and uninjured parts of my bones.

I had no idea what he was talking about. But he seemed knowledgeable and competent.

When he told me that if it were his arm he’d want the surgery done, I signed the consent form. I wanted a fully functioning left arm.

On my way out the door, I turned and asked my only relevant question of the day, “How many of these fixator things have you installed?” The surgeon gave a curious answer. They were fairly new, he said, but his practice group had installed three or four of them. I left without a second thought.

That’s when the trouble begins. And anyone considering surgery should read on and take notes. Continue reading

Doctor: Too Many Women Get Unnecessary Repeat Breast Cancer Surgery

Pathologist Stuart Schnitt (Bruce Wahl/BIDMC Media Services.)

By Karen Weintraub
Guest Contributor

As many as 30 percent of breast cancer patients have a second surgery because doctors worry they didn’t remove enough of the tumor the first time. But many of those repeat surgeries may be unnecessary, according to an essay published earlier this month in The New England Journal of Medicine.

One of the authors of that report, Dr. Stuart Schnitt, director of anatomic pathology at Beth Israel Deaconess Medical Center, spoke with me today about why he thinks these surgeries aren’t needed.

KW: It’s long been clear that lumpectomies are as good as mastectomies at preventing breast cancer from spreading. But doctors still don’t agree on the proper margins, that is, on how much of the tumor needs to be removed to prevent that spread?

SS: What constitutes an adequate negative margin has been a matter of debate for 20 years. Some surgeons say, “as long as there’s no tumor at the edge, I don’t care how close it is, it’s not a positive margin.” Others say: it’s got to be at least 1, 2 or 5 mm. But none of that is based on any data.

The other major thing is that the rules we went by 20 years ago have changed. Continue reading

When A Burst Appendix Doesn’t Kill You

An urgent laparoscopic appendectomy performed aboard the nuclear-powered aircraft carrier USS Enterprise (U.S. Navy via Wikimedia Commons)

First, the warning label for this story: A perforated appendix can kill you. If you experience symptoms of appendicitis, particularly sharp pain in the lower right area of your abdomen, get prompt medical care.

End of warning. Now for the surprising counter-example. You’ve seen acute appendicitis on hospital shows: The patient hunched over in unbearable stomach pain, rushed to the operating room for life-saving surgery to remove the organ gone awry. That’s the popular image of appendicitis, and it does reflect reality. Appendectomies are the most common emergency operation that general surgeons perform — at a rate of more than a quarter of a million a year.

But medicine is ever-evolving, and the thinking on appendectomies has been changing in recent years. Where once acute appendicitis meant an instant trip to the operating room, that call is now becoming somewhat more nuanced, and is likely to become still more refined in coming years.

Our case in point: WBUR’s news director, Martha Little. Her appendix has burst. And she’s been working in the newsroom this week as usual, burst appendix and all. No, this is not the ultimate workaholism. She explains:

A couple of weeks ago, I thought I had food poisoning. I came in to work late that Monday, but worked long days all the rest of that week with mild shooting pains across my upper intestines. I thought I had contracted some weird virus.

Then came the weekend. My kids, my husband and I went to Fairfield, Connecticut for a family reunion. After two days of whiffle ball and frolicking in the ocean I popped open a Phil’s Blackberry Cider, ate a brownie (I know, I eat like a kid) and got in to the lukewarm hot tub. About a half an hour later, I felt myself crumpling onto the front lawn with intense abdominal pain. Continue reading

First Total Artificial Heart Implant In New England: The Video

http://vimeo.com/44387011

Brigham and Women’s Hospital announced this morning that surgeons implanted the first total artificial heart in New England.

The Boston Globe reports:

The first total artificial heart implant in New England was performed last February on a 66-year-old retired high school teacher and track and field coach from the South Shore, who was diagnosed last year with a rapidly deteriorating condition that would have caused total heart failure.

The artificial heart that James Carelli received at Brigham and Women’s Hospital is intended as a bridge to a human heart transplant. Doctors diagnosed Carelli with cardiac senile amyloidosis, and they determined that his only option for survival was to receive the artificial heart while he awaits the transplant, according to an e-mail the hospital’s president, Betsy Nabel, sent Thursday morning to staff. He is on the waiting list for a heart transplant, as well as a kidney transplant.

Considering The Vasectomy

(kristykay22/Flickr)

Who knew a vasectomy could make such a great read? But here it is, in GQ, a gripping, hilarious, heart-breakingly honest account of one guy’s decision to take charge of family planning by knife.

As he awaits the surgeon, author Benjamin Percy notices the “walls are busy with gruesome anatomical diagrams, cross sections that make the male genitalia resemble charcuterie.” Then the action begins: “They go to work, flopping back my penis, arranging tools on a tray, positioning a stool between my legs. I squint into the blinding lights while the nurse snaps on latex gloves and my doctor shaves my scrotum. Then it’s time.”

Percy takes us through his decision to get a “v-sec,” noting that he loves, loves, loves his two children. “But a third?” he writes. “Outnumbered, we would have to switch from man-on-man to zone defense, and I can’t help but shudder when I imagine a red-faced baby wailing through the night, the bank statements withering further, the walls crayoned, and the laundry hampers reeking of spit-up and poo. An unexpected pregnancy, in other words, would be a nightmare.”

So he takes the plunge and makes a date with the surgeon:

I don’t scream, but I clamp my jaw so tightly it clicks. I arch my back so much I end up looking behind me at the door. The technique differs from doctor to doctor. Some cut diagonally. Some puncture “keyholes” with a hemostat on either side of the scrotum. Mine scalpels a vertical slash right down the middle. The room is cold, but I am sweating. How I regret not accepting the Valium. The doctor explains the procedure as it progresses. Apparently some men don’t have pronounced enough vas deferens, the tubes that carry sperm outward from the testicles, making the vasectomy impossible. But mine look great, he says. I would tell him thank you if I had a voice.

He will now sever the right vas deferens and excise a length of the tube, making recanalization close to impossible. “Now,” he says, his voice lowering, “you may feel a hot nauseating spike of pain that reaches up your right side.” Nobody I have spoken to, nothing I have read, mentioned anything about hot nauseating spikes of pain. Before I can steel myself to the idea, I hear a snip. The noise of garden shears deadheading geraniums.

I am unable to breathe. I cannot see what the doctor is doing, but he very well might have shoved a furnace-baked length of rebar through my groin and into my torso. I am introduced to vast, intricate networks of pain I never knew existed. Continue reading