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Ovarian and Uterine Cancer

“Dr. B, can we discuss early detection and prevention of cancers of the ovary and uterus?”

Sure, Susan. I will give you some information today and you discuss this further with your family doctor and/or gynecologist. Remember cancer of the uterus can be either in its body (endometrial) or in its opening (cervix).

In 1993, 606 Alberta women were diagnosed with invasive (beyond the superficial layer) cancers of the female genital organs: endometrial 256, ovary 203, cervix 122 and others 25. This does not include 1517 women who were diagnosed with in-situ (confined to the superficial layer) cancers of the cervix.

“What symptoms would I have if I had cancer of the ovary or uterus?”

Susan, unfortunately the early symptoms are none or very vague. Early diagnosis of ovarian cancer is more a matter of chance. Irregular vaginal bleeding may be the only early sign of uterine cancer. Hence, most of the gynecological cancers are picked up at a late stage. Of course, the Pap smear has completely changed the outcome of cervical cancers.

“Doctor, are there any risk factors which I should be aware of?”

Susan, for ovarian cancer, the risk factors are age (steady rise up to age 80) and family history. For endometrial cancer – age, obesity and estrogen therapy are major risk factors. For cervical cancer, the risk factors are well recognized. These are: some types of sexually transmitted disease(s), early age at first intercourse, and having multiple sexual partners.

“Doctor, what about screening tests?”

Susan, for ovarian and endometrial cancers, there are no recommendation for screening. But for cervical cancer, Pap smear is highly recommended. In U.S., this has reduced the incidence and death rate by 70 percent in the last 40 years.

Invasive cervical cancer is usually diagnosed between the ages of 45 and 50. But the average age of women with carcinoma in-situ is between 25 and 30 with evidence of increase in younger women. This could be related to risky health practices, such as experimenting with new ideas, relationships and activities during adolescence which may have long term adverse consequences.

“Dr. B, final question! How often should a woman get a Pap smear?”

Susan, for those who are not at high risk, first Pap smear should be done soon after the age of 18 or once the woman is sexually active. If this is normal and the one after a year is also normal then repeat after every three years until age 70.

It is very important for every woman to discuss her risk factors with her family doctor and/or gynecologist. Recommendations may vary. Any unexpected vaginal bleeding should be reported to your doctor to see if further investigation is required.

“Thank you, doctor,” Susan said as she got ready to leave my office. She continues to strive for good health for herself and her family. I admire her dedication.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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Do we really need disgruntled doctors?

Published on the editorial page of The Medicine Hat News, Wednesday, December 2, 1998, Page B6. At that time Dr. Bharwani was Regional Chief of Staff, Palliser Health Region, Medicine Hat, Alberta.

People keep asking me how the Palliser Health Authority got dragged into a situation which should be a Provincial issue?

It is a good question, but I do not have a good answer. What I know is that we have three very unhappy, angry Obstetricians – Obstetricians who have served this Region well for several years. They have kept our obstetrical care at the highest level in the Province, and they are fine family people who want to be appreciated and remunerated appropriately for what they do.

We are seeing a very sad situation. Angry, unhappy Obstetricians with a Health Authority strapped for money and pushed against the wall. “Give us the on call money or we quit” say the Obstetricians. But the Regional Health Authorities are not funded to pay for services provided by physicians.

The Obstetricians’ anger is only the tip of the iceberg. Physicians, in general, are angry and frustrated. They say, compare our hourly take home pay and lifestyle with those of dentists, lawyers, accountants, realtors, stockbrokers, bankers, etc.

This year the Canadian Medical Association conducted a survey on doctors’ attitudes and activities. This revealed that almost two-thirds of Canada’s physicians (62 percent) feel they are over worked, and more than half (55 percent) say that their family and personal life has suffered because they chose medicine as a profession.

Physicians feel that their income is declining even though their hours of work have increased. With the explosion of medical information on the Internet, the patient’s expectations have risen dramatically. In the era of cut backs, the physicians feel great pressure to satisfy their patients’ needs.

In a 1997 national survey of doctors, done by The Medical Post, the young doctors nationwide expressed extreme unhappiness with the health care system.

In Defense of the Obstetricians, From Where I Sit – 2

In the U.S.A, the situation is no different. In an editorial in The New England Journal of Medicine, Dr. Jerome Kassirier wonders if a health care system functions effectively if a sizable fraction of physicians are disgruntled. He asks, “Are patients well served by unhappy physicians?”

Physicians in the United States working in managed care organizations get financial incentives, which depend on limiting referrals, and care which would compromise their work. Physicians feel that incentives, which reward quality of care and provide patient satisfaction would offer better job satisfaction.

In his book “Paging Doctors”, David Woods, a medical journalist says, “The doctor’s dilemma, as George Bernard Shaw defined it in his play of that name, was the moral one imposed by getting paid for operating and not getting paid for not operating.” Bernard Shaw also raised some broader questions about the relative worth of people and objects. How do you define worth?

Finally, sixteen years ago, Modern Medicine of Canada wrote, “Doctors surely are stressed. The strain comes mainly from the profession that bears the most direct responsibility for other peoples quality of life and the nature and timing of their deaths. In fact, there is hardly a single human being living in a developed society who has not been treated by a physician several times in his life. But no matter how strenuously a doctor has toiled or how miraculous the results, it is all taken for granted and in this day and age, gratitude is minimal”.

So where do we go from here? The Palliser Health Authority would love to have happy doctors providing excellent quality service in an environment, which would recognize and reward their special skills. How can we do this?

I will leave you with these questions which were asked earlier: Can a health care system function effectively when a sizable fraction of the physicians are disgruntled? Are patients well served by unhappy physicians? Think about this, and tell me how we can keep our doctors happy and satisfied.

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Miscellaneous Health Topics

Some items of interest from the world of medicine:

1. Infant Homicide:

Infanticide (killing of a child in the first year of life) is the subject of a special article in a recent issue of The New England Journal of Medicine. The timing of the deaths, potential risk factors and prevention are discussed.

In Europe, in the early 1800s, up to a third of live-born infants were killed or abandoned by their parents. In the U.S., between 1983 and 1991, 2776 cases of infanticides are identified by the authors. The problem has not disappeared.

Studies have shown that homicide during the first week of life is usually committed by the mother. After that age, the culprit is usually a male, often the father or stepfather of the victim. In children three years and older, the perpetrator is usually unrelated to the victim.

On Friday, Nov 20th, The Medicine Hat News reported that three people in Salt Lake City are accused of murdering a three year old child-one of the accused being the child’s mother from Alberta.

So, what are the risk factors? Usually, the mother is young, has been pregnant before, has low level of education and gets late prenatal care. The infant has low birth weight, usually is a male who arrives earlier than due date.

How can we prevent infanticide? The authors of the special article feel that “…the identification of risk factors and interventions must take place during pregnancy, at the time of delivery, and in the immediate postpartum period.”

Studies have shown that child abuse can be reduced by home visits from trained nurses during pregnancy and in the first two years of life of a first-born child of an unmarried mother with low socio-economic status.

2. Do Rich People Live Longer?:

A U.S. study, on the above subject, is discussed in an editorial in one of the recent issues of the Annals of the Royal College of Physicians and Surgeons of Canada.

The study confirms the long held belief that the rich do live longer than the poor. But, this has nothing to do with the life style of the affluent. In fact, in U.S., the authors of the study found that the major factor for high death rate amongst the poor is due to inadequate access to timely and high quality health care.

3. What women don’t know could kill them:

This is the title of an article in a recent issue of The Canadian Medical Association Journal.

Most of us know that heart and blood vessel diseases are number one killer. Women make up 40 percent of these deaths. But, a recent Heart and Stroke Foundation survey shows that only 17 percent of the Canadian women are aware of this.

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Pancreatic Cancer

“Doc, few days ago, my neighbor’s wife, Yazmin, died of pancreatic cancer at the age of 59. Her husband, Yusuf, is devastated. He feels guilty. He thinks he could have done more to save her.”

Dave looks upset. I know when something is bothering him because normally he would say: What’s up doc? Busy today?

“Dave, here is some information which may help.”

Pancreatic cancer is the fifth leading cause of cancer death in North America. In 1992, 214 Albertans died of the disease (males 114, females 100). In 1993, 216 new cases were diagnosed in this province (males 98, females 118).

The prognosis is dismal. The overall 5 year survival rate is less than 2 percent, the worst of any cancer. Only 20 percent of the patients will be diagnosed at stage where surgery may offer hope.

The surgery is extensive with significant complications. Even those who survive the ordeal, the 5 year prognosis may not be better than 25 percent.

“Doc, why is it difficult to make an early diagnoses?”

Two main reasons: first, the pancreas is a long, narrow, transverse, deep seated organ behind the stomach in the upper abdomen; second, the initial symptoms are none or very vague. By the time ultrasound or CAT scan picks it up, it is too late.

Dave is surprised to hear that. He tells me about the difficulties Yusuf and Yazmin have overcome over the past 25 years. They had arrived penniless as refugees from Uganda with six children: the youngest, triplets, were about a year old.

Yusuf is a good watch repairer. After moving from few unsatisfactory jobs, he opened his own business: a jewelry shop. Yazmin did the “salesmanship” and Yusuf repaired watches. They were happy.

As parents, they had their share of problems raising children. Their oldest daughter has multiple sclerosis. Now, Yusuf has to deal with the tragedy of losing his wife.

Dave was almost in tears. “Doc, what causes pancreatic cancer?”

The precise cause is unknown. Smoking and chronic inflammation are suspected in the causation of the disease. An estimated 5-10 percent of pancreatic cancers are inherited and additional 10-20 percent may have other significant genetic influence (Current Oncology-July 1998).

“Doc, thanks for listening. I will go and see Yusuf. See if I can help him with the information I have.”

Good luck, Dave.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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