Author: noorali

Posted on

Male Breast Problems (Gynecomastia)

Dear Dr. B: Do men get breast problems?

Answer: Male breasts can have same sort of problems as female breasts. These problems are not common. But when they occur they should not be ignored.

In a healthy normal male, the breast is a rudimentary structure. The breast glands are small with fibrous tissue and some fat around the ducts.

The abnormalities of the male breast can be caused by congenital anomalies which may involve the breasts or the nipples. Male breasts do get problems which are inflammatory in nature, similar to what women get.

The most common problem I have seen is called gynecomastia. Gynecomastia is due to formation of firm tender tissue directly under the nipple. It may affect one breast or both breasts. In pseudo-gynecomastia, enlargement of the male breast occurs due to collection of excessive non-tender fatty tissue. Differentiation is important for investigation and management.

Gynecomastia can occur temporarily in 60 to 90 per cent of the newborns because of the passage of estrogen (female sex hormone) through the placenta.

Gynecomastia can occur during puberty. This can be anywhere from the age of 10 and peaking between the ages of 13 and 14. Then it declines during the late teenage years.

Gynecomastia can occur in the adult population as well. This occurs usually between the ages of 50 to 80.

At birth, the breast tissues of both sexes appear identical. The tissues remain dormant during childhood. At the time of puberty, the male and female breast tissues start showing features of different development.

Gynecomastia can be due to chromosomal abnormalities, endocrine function, and consumption of hormones or drug therapy. Fifty per cent of gynecomastia are of unknown origin or due to puberty. About 20 per cent are due to drugs. The rest are due to testicular tumours or poor testicular function or over active thyroid or kidney disease.

Breast cancer is a possibility but very rare in males. The lump is usually hard, non-tender and can be anywhere in the breast. There may be bloody nipple discharge. There may be dimpling of the skin.

How should we investigate?

All patients need full history (including previous medical problems and use or abuse of medications) and full physical examination (especially examinations of the testicles to see if there is a tumor).

If there is nothing significant to find then most teens do not require extensive blood work because most gynecomastia are part of growing up. A periodic follow-up may be advised. In 90 per cent of teenage boys, gynecomastia goes away in less than 3 years.

Gynecomastia can be due to increased production or decreased breakdown of estrogen, which may indicate a hormonal or liver function work-up (blood tests).

In adults, sometimes the problem can be solved by stopping the medications. Rarely, surgery may be necessary to remove the extra breast tissue.

If a breast enlargement is one sided, hard, and nodular, it is very important to perform a biopsy and mammogram to rule out breast cancer.

If gynecomastia is due to disease or tumor then further treatment is required.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Posted on

What’s New in Breast Cancer

Photograph shows a patient with advanced breast cancer.

Photograph shows a patient with advanced breast cancer.

Dear Dr. B: What’s new in breast cancer?

Answer: There are many good things happening in the field of breast cancer. To start with the prognosis is getting better. Nearly 98 per cent of women with early-stage breast cancer will survive at least five years. Most of these women will live a long healthy life.

But the bad news is the incidence of breast cancer is increasing. The numbers have been rising steadily since screening was established about 15 years ago. Because of the better screening methods more breast cancers are picked up at earlier stage with better cure rate. So, it is a mixture of bad news with good news. Without screening these cases would have eventually come to the surface (so to speak) probably with poor prognosis.

There is more good news. A recent trial showed Herceptin (trastuzumab), a drug used for late-stage breast cancer also helps women with early-stage breast cancer. The drug reduced recurrence of breast cancer by 50 per cent in early-stage breast cancer. It is useful in 20 to 30 per cent of these women whose tumours are HER2- positive.

Since 1999, Herceptin has been used in hospital setting for women with metastatic breast cancer. There was no funding for patients with non-metastatic breast cancer. It is an expensive drug. The annual cost of the drug per patient is $35,000-$45,000.

An article in the Canadian Medical Association Journal (Patient demand and politics push Herceptin forward) says some provinces have expanded funding for Herceptin to include non-metastatic breast cancer patients. The provinces are: British Columbia, Ontario, Saskatchewan and Quebec. Nova Scotia and PEI are extending availability on case-by-case basis. Women with breast cancer were happy to hear this. Alberta is in the process of finalizing the approval process.

All experts do not agree that such large amount of money should be spent on a small number of patients to gain few months of survival time. If the drug is curative then there would be no argument. But cure for cancer is no where in site. We just take baby steps and look for good news where ever we can find it. And there is no harm in experts debating issues. After all we live in a democracy. Let the best argument prevail.

The debate about the diagnostic accuracy of mammograms for screening purposes has been going on for many years. There is no dispute about the appropriateness of breast cancer screening in women aged 50-69 years. But the sensitivity of mammography in detecting breast cancer depends on the patient’s age, the size and location of the lesion, the hormone status of the tumour, and density of a woman’s breast, the overall image quality and the interpretative skills of the radiologist. So, mammography is good but not perfect.

What about obesity? Yes, weight gain increases breast cancer risk possibly due to excess estrogen derived from fatty tissue. Obese women are twice as likely to die from breast cancer. Women can reduce the risk of breast cancer by taking care of their weight. Studies have shown that there is an association between physical activity and breast cancer prevention. Physical activity also reduces the risk of cardiovascular disease and diabetes.

Those women who do not exercise regularly should take up the challenge. Most women do a great job looking after their families, but in the process they forget about themselves. An ounce of selfishness may be good for the rest of the family! As long as my dinner is ready when I come home!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Posted on

Miscellaneous Medical News

In September, 2002 a mosquito bit a Toronto resident, George Eliopoulos. He subsequently died due to West Nile virus. Eliopoulos was in his 60s. His family is now suing the Ontario government alleging it failed to properly implement its 2001 West Nile virus surveillance and prevention plan.

The case is slowly going through the judicial system. Bill Rogers, legal columnist for the Medical Post says the Ontario government has lost two written judicial pronouncements. But the case is far from over. The court has still to decide whether this case can go to court.

There are 40 other individuals who contracted West Nile virus in 2002 are also suing the Ontario government.

The law suits claim that the government of Ontario’s May 2001 plan for surveillance and prevention of West Nile virus was deficient and the government failed to implement it in a reasonable and careful manner.

One of the issues the court has to decide is whether Ontario government’s West Nile virus plan was a government policy. If so, then governments cannot be sued for their policy, says Rogers. The court will also decide if government negligence caused deaths due to West Nile virus.

*********************************************

A report in the Canadian Medical Association Journal (CMAJ) says doctor shortage is increasing in Canada. The proportion of family physicians accepting new patients declined from 23.7 per cent in 2001 to 20.2 per cent in 2004. This shortage is going to get worse as 3800 physicians plan to retire this year.

Currently, 24 per cent of Canada’s doctors are international medical graduates. In Saskatchewan, more than 50 per cent of doctors are international medical graduates.

Part of the problem, says CMAJ report, is that there are only 6.5 medical school positions per 100,000 population in Canada compared to 12.2 openings in the U.K. The second problem is lack of sufficient residency programs. If medical school positions are increased then the residency programs will have to be expanded. When is this going to happen?

In the meantime, Canadians are living longer and their health care needs are increasing. The big question is: Are we ever going to have enough doctors, nurses and other health care professionals to provide appropriate care to those who need it?

***********************************************

Is your doctor following his own advice?

Yes, says a report in the Medical Post. At least, the majority of them are taking actions to stay healthy.

A Harvard Medical School study says most doctors make an effort to eat wisely and many make a point of working out regularly. Here are some of the findings of a survey of 15,000 physicians:

-82 per cent eat breakfast regularly and consume at least three servings of fruit or vegetables

-only 12 per cent admitted to eating fast food

-nearly 60 per cent chose olive oil over less healthy fats

-about 50 per cent drink alcohol in moderation (fewer than five drinks a week)

– 78 per cent take vitamin supplements regularly

-doctors older than 50, 75 per cent said they had under gone colonoscopy and 84 per cent had PSA test done

-two-thirds of the women older than 40 have had annual mammogram

-majority of the physicians exercised minimum of three times a week

Looks like the majority of the doctors practise what they preach.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Posted on

Celiac Disease

Nancy Kershaw
Photograph shows Nancy Kershaw making a presentation at the celiac disease support group that meets regularly at the Church of the Nazarene in Medicine Hat.

Dear Dr. B: October is Celiac Awareness Month. Recently diagnosed, I find no one truly knows what it is. I didn’t know anything about it prior to diagnosis. I would like people to know how difficult it is to live with celiac disease food-wise.

Answer: Celiac disease (CD) is a lifelong autoimmune intestinal disorder and runs in families. First degree relatives of individuals with CD may or may not manifest symptoms of the disease. It affects people to varying degrees, from being critically ill to being completely well.

In Medicine Hat, there is a support group that meets regularly at the Church of the Nazarene. Currently the support group is run by Nancy Kershaw. Nancy was born with CD. She had diarrhea, bloating, anemia and malnutrition. She was diagnosed to have CD and put on gluten free diet. She did alright after that.

That was many years ago. Now Nancy is a mother of three grown-up children. But she continues to adhere to gluten free diet. Any departure from the rigid diet regime and the symptoms come back.

Gluten is the common name for the offending proteins in specific cereal grains that are harmful to persons with CD. When gluten is ingested, it causes immunologically toxic reaction in the lining of the small intestine. The small intestine is lined by villi which help absorb the nutrients from the food we eat. The toxic reaction damages these villi thus interfering with the absorption of nutrients and leading to diarrhea and malnutrition.

According to medical literature, the “Coeliac Affection” was first reported by Gee in 1888. It was not until 1950 that wheat was proposed to be the cause of CD. The evidence was based on the observation of a Dutch physician named Dicke who noted during World War II, a time when wheat grains were scarce in Holland that children with CD who had otherwise failed to thrive improved on a wheat-poor diet.

Diagnosis of CD is based on symptoms and tests. There are several immunological blood tests available to make a diagnosis of CD. But the only confirmatory test is a small bowel biopsy done during gastroscopy.

A person should not be prescribed gluten free diet until the biopsy has confirmed the diagnosis. Abnormality in small bowel disappears once the person strictly follows gluten free diet.

Nancy says CD support group was started in Medicine Hat about three years ago. About 12 to 20 people attend the meeting. Nancy feels that there are more people in Medicine Hat with CD but are not aware of the support group. At the group meetings the attendees share food and recipes and talk about their experience with CD.

Nancy says some businesses and restaurants in Medicine Hat have been very supportive. For example, Nutter’s has been very generous with their food supplies for the support group. They are more than willing to stock gluten-free food in their stores.

Nancy says Moxie’s Restaurant has gluten-free food menu. In fact, any restaurant would be able to help a person with special diet requirement if a person phones the restaurant in advance.

Once CD is diagnosed, it is prudent to stay on a life-long gluten-free diet. It is not easy. But you can ask for help. The support group meets second Wednesday of each month at 7:00 p.m. at the Church of the Nazarene. Please contact Nancy at 526-0772 or Christine at 526-9524 for more information.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!