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Detecting Breast Cancer in Women with Dense Breasts Made Easier

Valley of the Kings, located on the west bank of the Nile, Egypt. (Dr. Noorali Bharwani)
Valley of the Kings, located on the west bank of the Nile, Egypt. (Dr. Noorali Bharwani)

The Canadian Cancer Society recommends that all women 50 to 69 years of age be screened for breast cancer every two years, using mammography. But mammography is less useful in identifying cancerous tissue in women with dense breasts; that is, women whose breasts have less fatty tissue but have more fibrous tissue.

In Canada, more than one million women (that is 50 per cent of women) who are 50 to 69 years old have dense breasts. Mammography is not a good test for picking up breast cancer in women with dense breasts. These women are being offered an additional test in the U.S. at a cost of about U.S. $2000 (two thousand). This test is called molecular breast imaging (MBI). This is not the first line of investigation for breast lumps. All women who are eligible for breast screening first undergo mammography and if necessary ultrasound to see if a lump is solid or cystic. Women with dense breasts then can be offered MBI if the mammogram is negative.

In a study from Mayo Clinic, 2600 women with dense breasts underwent mammogram and then MBI. Thirty two per cent of women were found to have breast cancer. Of these only eight breast cancers were picked-up by mammogram alone but 29 breast cancers were picked up by mammography plus MBI. This test is four times better than mammogram alone, is less painful and gives better pictures. However, this is not the final answer. More research is in progress to see how the results can be improved.

MBI is not going to replace mammography. Mammograms will remain the gold standard in breast cancer screening and will continue to be the standard first step in breast cancer detection. Use of MBI, MRI (magnetic resonance imaging) and ultrasound will continue to serve special populations of patients who need tests beyond a mammography.

Breast MRI is not recommended as a screening tool for women who are at average risk of developing breast cancer. It is better than mammogram but a major disadvantage is that breast MRI screening results in more false positives. In other words, the test finds something that initially looks suspicious but turns out not to be cancer. To avoid unnecessary biopsies MRI screening is reserved for high-risk women only. MRI is also more expensive and not widely available.

In conclusion, mammograms are probably the most important tool doctors have, not only to screen for breast cancer, but also to diagnose, evaluate, and follow people who’ve had breast cancer. It is safe and reasonably accurate. The technique has been in use for more than 50 years. MBI is still being tested, but it appears to hold promise for detecting breast cancer in women who are at higher-than-average risk for the disease and have dense breasts. Ultrasound and MRI is used for special cases.

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Increased E-cigarette Use in High Schools

South Saskatchewan River in Medicine Hat, Alberta. (Dr. Noorali Bharwani)
South Saskatchewan River in Medicine Hat, Alberta. (Dr. Noorali Bharwani)

Cigarette smoking is dangerously addictive and lethal. Now there are new concerns with the introduction of electronic cigarettes or e-cigarettes.

E-cigarettes are cigarette-shaped canisters used to simulate the action of cigarette smoking.
The e-cigarettes are fluid-filled cartridges that contain varying concentrations of flavouring agents, propylene glycol, glycerine, water and other chemicals. The batteries within the canisters heat up contents of the e-cigarette.

Some e-cigarettes contain nicotine. The cartridge content varies widely according to the manufacturer and distributor. The act of smoking an e-cigarette is called “vaping,” because the user inhales vapour, not smoke.

A new study by Khoury and colleagues published in the Canadian Medical Association Journal (CMAJ August 9, 2016) reports that 10 per cent of a representative sample of grade 9 students in Ontario had tried electronic cigarettes (e-cigarettes).

An editorial in the CMAJ says this finding is likely an underestimate of rates across Canada. For example rates in Quebec are double those in Ontario.

Usually smokers start using e-cigarettes to kick the smoking habit. But Khoury and colleagues found that most smokers were motivated to try e-cigarettes by their novelty and “coolness” – rarely did youth use e-cigarettes to quit smoking.

The study found e-cigarette use was highest among the most vulnerable youth who are in poor health, high stress or low socioeconomic status. The study also confirmed that most were not substituting e-cigarettes for cigarettes: instead, the odds of e-cigarette use were 12-fold higher in youth who also smoked cigarettes (i.e. “dual users”).

Evidence shows increasing use of e-cigarettes in Canada and U.S. A recent study in the US involving youth found that those who did not smoke from grades 11 to 12 and used e-cigarettes, had six fold higher odds of becoming cigarette smokers a year and a half later when they reached the legal age to purchase tobacco. The typical fruit and candy flavourings of e-cigarette liquids are the number one reason they appeal to youth.

What is the government doing about this?

In Canada, governments have begun to take action to protect our youth from e-cigarettes. Ontario and seven other provinces have now passed or tabled legislation that treats e-cigarettes similarly to tobacco products – including a prohibition on selling or supplying them to minors, says the CMAJ editorial.

There is no good reason for youth – or any non-smokers – to be using e-cigarettes. Nothing good can come of providing vulnerable individuals with a more appealing way to become addicted to nicotine, says the editorial.

Some of the things the government can do are: prohibit flavourings in e-cigarettes and introduce advertising restrictions currently in place for tobacco products.

Parents and teachers have an important role to play in engaging our youth in a conversation about the harms of e-cigarettes, lest we lose the progress against tobacco that we have worked so hard for decades to achieve, says the editorial.

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Safe Use of Acetaminophen (Tylenol)

Concentration. (Dr. Noorali Bharwani)
Concentration. (Dr. Noorali Bharwani)

Let us start with the use of acetaminophen (Tylenol) in pregnancy. Acetaminophen is generally considered safe in all stages of pregnancy because it doesn’t have the same risks as other over the counter painkillers.

But new animal research says otherwise. Studies following birth outcomes in Denmark and New Zealand have suggested that the use of acetaminophen in pregnancy may be associated with behavioural problems in the new born. Studies carried out in animal models suggest the drug seems to disrupt hormonal function and brain development.

A British study on humans (published in JAMA Pediatrics August 15, 2016) suggests children born to women who used acetaminophen during pregnancy could be at increased risk for several behavioural problems.

The British researchers followed about 14,000 pregnant women who were expected to deliver in 1991 or 1992. They collected detailed information, through clinical visits and questionnaires, about the health and development of the children until the age of seven and looked at the genetic risk factors.

Children born to women who took acetaminophen during the second trimester (18 weeks) and the third trimester (32 weeks) showed emotional problems and behavioural difficulties.

Children born to mothers who took the drug during the third trimester, about six out of 100, had behavioural difficulties – compared with four out of 100 whose mothers did not take the drug.

There was no association with the mother’s use of acetaminophen after giving birth or a partner’s use of acetaminophen. The researchers did not have any information on the dose taken or for how long.

What now?

Some experts believe more research is needed to understand the mechanism of action of acetaminophen during pregnancy. Until we understand this fully, pregnant mothers should follow their physicians’ advice because there is a risk to the fetus of not using acetaminophen when it is required. For example, fever during pregnancy can be dangerous and can lead to pre-term labour.

The bottom line is more research is required. We need to know the dose and duration of acetaminophen use which can be risky. As far as we know, there is no risk when acetaminophen is used during the first trimester.

Under normal circumstances if acetaminophen is taken too often it can cause liver damage. Acetaminophen is a medicinal ingredient in more than 470 products. That is lot of drugs.

There are stricter guidelines and warnings in the U.S. on the safe use of acetaminophen. This move comes as Johnson & Johnson, the makers of Tylenol, face more than 85 personal injury lawsuits in U.S. federal court that blame Tylenol for liver injuries and deaths. The U.S. Food and Drug Administration is planning to curtail the use of some acetaminophen products. The maximum daily dose is 4 grams, in people with healthy liver and kidneys.

Acetaminophen was discovered in 1877. It is used to treat mild to moderate pain and fever. There is poor evidence for fever relief in children. It is typically taken by mouth or rectally, but is also available intravenously. Effects last between two and four hours.

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Eating the Right Kind of Protein

A rock formation in Barbuda! (Dr. Noorali Bharwani)
A rock formation in Barbuda! (Dr. Noorali Bharwani)

A balanced diet consists of carbohydrates, proteins, fats and fruits and vegetables to provide you with vitamins, minerals and other nutrients.

Proteins are considered essential nutrients for the human body. They are one of the building blocks of body tissue, and can also serve as a fuel source. The body needs protein for growth and maintenance. Aside from water, proteins are the most abundant kind of molecules in the body.

There are many sources of protein: grains, legumes, nuts, seeds as well as animal sources such as meats, dairy products, fish and eggs. Vegetarians and vegans can get enough essential proteins (amino acids) by eating a variety of plant proteins.

A recent study from Harvard University and Massachusetts General Hospital in Boston (published in JAMA Internal Medicine) shows people who eat more protein from plants and less from animals may live longer even when they have unhealthy habits like heavy drinking or smoking.

If you like to eat animal protein then you should avoid processed red meat and choose fish or chicken instead.

The Harvard researchers followed more than 130,000 nurses and other health professionals over several decades. Half of the participants were getting at least 14 per cent of their calories from animal protein such as meat, eggs and dairy and at least four per cent from plant protein sources such as pasta, grains, nuts, beans and legumes.

The researchers noted that previous studies have indicated eating fewer starchy foods and more protein can help people manage their weight, blood pressure, sugar and blood lipids. But the Harvard study shows animal protein is deadlier for individuals who were obese or heavy drinkers.

The researchers found that meat eaters with an unhealthy lifestyle and higher mortality risk tended to eat more red meat, eggs and high-fat dairy than the fish and poultry eaters favoured by those with a healthy lifestyle.

The new study also found that meat eaters with a healthy lifestyle tended to consume more fish and poultry, while those with an unhealthy lifestyle and higher mortality risk – such as those who were overweight and drank at least one alcoholic beverage per day – tended to eat more red meat, eggs and high-fat dairy.

The authors say the study cannot prove that the type of protein people eat directly influences how long they may live. It’s also possible that the eating and lifestyle habits of health-care workers (participants in this study) might not be representative of the broader population of adults.

The real risk of mortality from animal protein also appears largely tied to processed meat, such as bacon, salami and hot dogs.

The take-home message here is to eat specific healthier plant-based foods such as fruits, nuts, seeds, beans, and non-starchy veggies. Avoid dangerous plant-based foods such as French fries to soda to white bread and white rice. And pursue a healthier life-style.

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