What is the best test for breast cancer screening?

A bird on a fall day. (Dr. Noorali Bharwani)
A bird on a fall day. (Dr. Noorali Bharwani)

Is MRI test better than mammography for early detection of breast cancer?

This question applies to women who are at average risk of breast cancer. They have no personal or family history of breast cancer. The controversy over the best way to screen for breast cancer among women at average risk continues.

Regular screening for breast cancer with mammography, breast self-examinations and clinical breast examinations are widely recommended to reduce mortality due to breast cancer.

Unfortunately, the available evidence does not support the use of MRI scans, clinical breast examination or breast self-examination to screen for breast cancer among women at average risk. But we continue to use these investigations.

Recent publications have again questioned the use of MRI alone or in combination with mammography for breast screening. There are more false-positives resulting in more negative biopsies.

Some researchers (JAMA Intern Med. 2018 Apr 1) have concluded that screening with MRI is not for everyone. Women who undergo breast cancer screening with MRI are much more likely to be referred for biopsy – that will ultimately be negative – than if they have screening mammography alone.

The authors of the article warn, “This is even true of women with a personal history of breast cancer. The benefit of possible early detection of breast cancer with MRI has to be carefully weighed against unnecessary additional diagnostic manoeuvres.”

Other authors have concluded that more studies are required to identify women who will benefit from screening MRI to ensure an acceptable benefit-to-harm ratio.

The experts have to determine whether a screening test would benefit or harm the patient. There is risk of harm and cost of false-positive results, overdiagnosis and overtreatment. How many unnecessary biopsies will be done to find one cancer? How many women will have to anxiously wait for days, weeks or months to find out if they have cancer? Not easy questions to answer unless you are sailing in the same boat.

Any positive result from screening has emotional costs such as anxiety and worry for patients and their families, and financial costs to both the patient and the health care system as a result of additional and potentially unnecessary diagnostic tests.

For women with positive results on screening tests, additional diagnostic tests will usually be recommended, such as further mammography, ultrasound and/or tissue sampling with core needle biopsy.

You may ask, “Doctor, what is the best way to screen asymptomatic women with no personal or family history of breast cancer?” The answer lies in the following recommendations from the Canadian Cancer Society:

If you are 40–49: Talk to your doctor about your risk for breast cancer, along with the benefits and potential risks of mammography. The benefits of regular mammography to screen for breast cancer in women younger than 50 are still unclear.

If you are 50–69: Have a screening mammography every 2 years.

If you are 70 or older: Talk to your doctor about how often you should have a mammography.

There is some radiation involved in having mammography. The benefits of mammography and finding breast cancer early outweigh the risk of exposure to the small amount of radiation received during mammography.

Now, here is the good news. The average 5-year survival rate for people with breast cancer is 90 per cent. The average 10-year survival rate is 83 per cent. If the cancer is located only in the breast, the 5-year relative survival rate is 99 per cent. Sixty-two percent of cases are diagnosed at this stage.

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There is some good news for children with peanut allergy.

The White House - Let there be peace! (Dr. Noorali Bharwani)
The White House - Let there be peace! (Dr. Noorali Bharwani)

Allergy to peanuts is the most common children’s food allergy. And the prevalence of peanut allergy is rising. It tends to present early in life, and affected individuals generally do not outgrow it. It is not clear why some people develop allergies while others don’t.

Eight foods are responsible for more than 90 per cent of food allergies: cow’s milk, eggs, soy, wheat, peanuts, tree nuts (walnuts, hazelnuts, almonds, cashews, pecans and pistachios), fish and shellfish. Peanuts and tree nuts are responsible for the majority of serious acute allergic (anaphylactic) reactions.

While EpiPens are used to control general allergic reactions, there is no specific treatment available for peanut allergies – until now. A Harvard University blog of March 1, 2018 (A cure for peanut allergies in sight?) reports that within the past year, three new peanut allergy therapies have gone through clinical trials.

Despite the treatment’s success, there were some safety concerns: 20 per cent of patients discontinued the trial, with 12 per cent withdrawing due to moderate side effects. But there is still hope. The researchers are planning to get FDA approval, which would make it the first protective treatment against peanut allergies, says the Harvard University blog. We have to learn more about the complex mechanisms of peanut allergy and tolerance before success is achieved.

Food allergies affect between four and eight per cent of children and between one and two per cent of adults. The perceived prevalence of food allergies is substantially higher than the actual prevalence. Up to 30 per cent of the general population believe they have a food allergy, and up to 30 per cent of parents believe that their children have a food allergy.

All food allergies have the potential to induce anaphylaxis, but some foods are more likely than others to cause potentially life-threatening reactions. Peanut allergy deserves particular attention. It accounts for the majority of severe food-related allergic reactions, it tends to present early in life, it does not usually resolve, and in highly sensitized people, trace quantities can induce an allergic reaction.

Parents have to understand that all degree of peanut allergy should be taken seriously – even mild allergy can cause serious problems. An allergic response to peanuts usually occurs within minutes after exposure.

Should pregnant women avoid peanuts to prevent peanut allergy in their children?

We need more studies to advise pregnant mothers about avoiding peanuts during pregnancy. We have no evidence to suggest that pregnant women should be encouraged to ingest peanut or suggest an amount of peanut to be ingested to ensure a preventive effect, as there is insufficient evidence to support it at this time, say experts.

To summarize, peanut allergy is the most common cause of food-induced anaphylaxis, a medical emergency that requires treatment with an epinephrine (adrenaline) injector (EpiPen) and a trip to the emergency room.

Call 911 if you or someone else displays severe dizziness, severe trouble breathing or loss of consciousness. There is no time to waste.

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Minimally invasive surgery has revolutionized surgical procedures.

Central Park in New York City. (Dr. Noorali Bharwani)
Central Park in New York City. (Dr. Noorali Bharwani)

In minimally invasive surgery, doctors use a variety of techniques to operate with less damage to the body than with open surgery. Minimally invasive surgery is associated with less pain, a shorter hospital stay and fewer complications.

This advantage is achieved by using a technique called laparoscopy where surgery is done through one or more small incisions, using small tubes and tiny cameras and surgical instruments.

Laparoscopic technique was one of the first types of minimally invasive surgery. Another type of minimally invasive surgery is robotic surgery. It provides a magnified, 3-D view of the surgical site and helps the surgeon operate with precision, flexibility and control.

It was in 1902, Georg Kelling from Dresden in Germany performed laparoscopic surgery using dogs. In 1910, Hans Christian Jacobaeus from Sweden used the approach to operate on a human. Over the next couple of decades, the procedure was refined and popularized by a number of people.

Laparoscopic gallbladder surgery (cholecystectomy) was introduced about 25 years ago. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in North America.

Now laparoscopy has become the approach of choice for cholecystectomy. Other laparoscopic surgical procedures are appendectomy, nephrectomy, hysterectomy and other gynecological procedures. Just like anything else in life, these procedures are not without complications – during or after surgery.

If the laparoscopic surgery is difficult to perform and if the surgeon feels this may cause harm to the patient then the procedure is converted into an open one. Patient has to understand this and give consent to the surgeon to do whatever is safe for the patient.

To make sure that the surgical procedures are carried out safely, the operating room follows a protocol, which takes into account the following:

  • Perform a surgical pause (time out) to confirm the procedure with the team prior to initiating surgery.
  • Verify that the correct materials or equipment was available and functional prior to use.
  • Consider potential harm from misuse of surgical equipment.

Possible intra-operative injuries include damage to the bowel, blood vessels, ureter, reproductive organs, or nerves. The complication rate during surgery increase if the patient is obese and there are adhesions from previous surgeries.

How quickly you can return to normal activities after a cholecystectomy depends on which procedure your surgeon uses and your overall health. People undergoing a laparoscopic cholecystectomy may be able to go back to work in a matter of days. Those undergoing an open cholecystectomy may need a week or more to recover enough to return to work.

In 95 per cent of people undergoing cholecystectomy as treatment for simple biliary colic, removing the gallbladder completely resolves their symptoms. Up to 10 per cent of people who undergo cholecystectomy develop a condition called post-cholecystectomy syndrome. That means patient has symptoms typically similar to the pain and discomfort of biliary colic. Small number of patients may get chronic diarrhea after surgery. This can be controlled with medication like cholesteramine.

Overall, it is a very safe procedure.

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What you should know about medical assistance in dying – MAID?

Toronto Waterfront (Alia Bharwani)
Toronto Waterfront (Alia Bharwani)

“I’m not afraid of being dead. I’m just afraid of what you might have to go through to get there,” said Pamela Bone. Bone, 68, was a columnist and associate editor of the Age, one of Australia’s most respected newspapers. She died of terminal cancer. She was also a passionate campaigner on the right to die.

In Canada, following a Supreme Court ruling, medical assistance in dying became legal on June 6, 2016.

Recently (June 2018), the Canadian Medical Protective Association (CMPA) wrote, “Despite current federal and Québec legislation that makes medical assistance in dying (MAID) legal, there continues to be uncertainty among some physicians about their rights and obligations, and the processes to be followed in this area.”

A June 2016 Canadian Medical Association (CMA) survey revealed 25 per cent of responders (doctors) would be willing to provide MAID and 61 percent would not. Under the new law, Canadian doctors are not compelled to provide MAID. In these cases, the doctor is required to provide a referral to a health care professional or agency willing to carry out the patient’s wishes.

What kind of challenges physicians may face in determining eligibility for MAID? CMPA says there are several areas of concern. First, how can a doctor define and predict “reasonably foreseeable death” before enlisting an individual for MAID? Can a doctor be a conscientious objector if MAID does not agree with his/her beliefs? And there are other issues not well defined in the law.

Court challenges are underway in British Columbia and Québec in which the issue is whether the requirement that “natural death be reasonably foreseeable” is too restrictive and violates patients’ constitutional rights.

Physicians should remember that unlike most other healthcare services, MAID is governed by criminal law. Failure to ensure that the safeguards and eligibility criteria, as well as the reporting requirements for MAID are met could result in criminal charges and imprisonment of up to 14 years, in addition to College sanctions, civil legal actions, or both, says CMPA.

There are several other issues to be considered when implementing MAID:

  • Is there a risk that the law will be abused to weed out society’s undesirable people? In Canada, patients need to meet specific eligibility criteria put in place to safeguard vulnerable people. The patient must be mentally competent and give informed consent.
  • Is MAID a legal way to commit suicide? Committing suicide and going through physician-assisted dying are legally two different things. A medically assisted death is well planned and thought out, while suicide is often impulsive, violent and carried out alone.
  • Prior to Canada’s new law, it was illegal for anyone to counsel or coerce someone to die by suicide. The current Criminal Code now includes an exemption for physicians, nurse practitioners, and pharmacists – they are now allowed to counsel patients.

Alberta Health says its goal is to provide access to physician-assisted death, while protecting vulnerable Albertans and respecting the rights of physicians and other health professionals. To achieve this goal, the law should provide better clarity to protect the health care providers if they have to help those who are eligible for MAID.

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