Heart surgery 2nd opinion center

For years, we have been reporting the overuse of the coronary artery-opening procedure called angioplasty, aka percutaneous coronary intervention. About one million people in the U.S. undergo this procedure annually; despite the fact that well-designed clinical trials proved that many are in non-emergency situations and can be treated just as effectively with the multiple drug therapy. These are the same drugs, by the way, that most people will be told to take after they’ve had an angioplasty. The procedure, done in non-emergency situations, has a death rate of at least 0.63%.

Lown Cardiovascular Center, Brookline, Massachusetts is the place to go if you want a second opinion about the necessity of angioplasty or coronary bypass surgery. Long-time readers may recognize the name of cardiologist Thomas Graboys, MD, of the Lown Cardiovascular Center, who was frequently quoted in HealthFacts over the years, expressing concern that angioplasty had become a cash cow for many hospitals. In one memorable interview, he said that many symptomless people are scared into undergoing angioplasty after “failing” a stress test and told they are sitting on a “time bomb.” Such people, he said, could have been safely treated with daily aspirin and avoided the procedure.

Dr. Graboys, professor of medicine at Harvard Medical School, first came to our attention in 1992 when he co-authored a seminal study showing that angioplasty can be safely deferred in many people who have been told that the procedure is urgently needed. This and many other studies he co-authored over the years led him to recommend a second opinion when a cardiac catheterization is advised because this diagnostic procedure puts people on the proverbial conveyer belt to having an angioplasty or coronary bypass surgery. Sadly, Dr. Graboys is no longer with the Lown Cardiovascular Center. He was forced into premature retirement in 2006 due to Parkinson’s disease and dementia. He wrote a book about the experience called Life in the Balance.

Visit the Lown Cardiovascular Center Web site to see what a second opinion involves and to read the bios of the six cardiologists on the staff and no cardiovascular surgeons. Let us know if there’s a similar center in your area.

Maryann Napoli,Center for Medical Consumers(c)

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Second pathology opinion for mammography-detected breast cancer

“Screening causes cancer.” When British surgeon and screening critic Michael Baum, MD, once expressed this opinion during a protracted media controversy over the safety of mammograms, it, no doubt, struck many as hyperbole. A recent study of mammography screening in Norway and Sweden, however, shows the comment to have a strong element of truth.

These two Scandinavian countries provide the basis for testing out a prevailing theory about the benefit of screening. Yes, many more cancers are diagnosed once a screening program is introduced, goes the theory, but they are “tomorrow’s cancers” diagnosed today. Then there are the skeptics who look at the long-range statistics and see something quite different. The increase in “tomorrow’s cancers” found in a large group of middle-aged women given regular mammograms, they reason, should eventually result in a corresponding decrease in breast cancer diagnosed later in life.

The skeptics were validated in the Scandinavian study published recently in the British electronic journal, BMJ Online First. After mammography screening was introduced in Norway for women aged 50 to 69 years, the incidence of breast cancer had increased by 54%, according to Per-Henrik Zahl and colleagues at the Norwegian Institute of Public Health, Oslo. The increase was 45% after mammography screening began in Sweden in 1987. Contrary to expectations, there was no corresponding long-term reduction in the rate of women diagnosed with breast cancer. Dr. Zahl and colleagues wrote that the increases in breast cancer incidence were too large to be attributed to causes other than screening, such as hormone therapy.

The significance of these findings is this: Mammography causes many women to be diagnosed and treated for a type of breast cancer that would never produce symptoms or become life threatening if left undetected. Doctors call this overdiagnosis and overtreatment. Unfortunately, most women are not informed of this risk, as they should be, before they consent to mammography screening. A survey of U.S. women’s attitudes toward mammography screening in 2000 showed that only 6% had ever heard that mammograms can find cancers that do not progress.

Whenever researchers address the problems associated with overdiagnosis and overtreatment, they usually focus on the mammography-related massive increases in the diagnosis of ductal carcinoma in situ (DCIS), a type of microscopic cancerous lesion within the milk duct that, in most cases does not progress to life-threatening disease if left untreated. (At least 60% of DCIS will not go on to become invasive and life threatening.).

Dr. Zahl and colleagues, however, have confined their statistics solely to invasive breast cancers, which makes their results even more alarming. The only way women can protect themselves from overtreatment is to give serious thought to the decision whether or not to undergo mammography screening. The risks associated with overdiagnosis and overtreatment are significant enough to make avoiding mammography a reasonable choice for women without breast symptoms. After looking at their survey results, Dr. Zahl and colleagues concluded, “Without screening, one third of all invasive breast cancer in the age group 50-69 years would not have been detected in the patients’ lifetime. This level of overdiagnosis is larger than previously reported.”

Another element of the mammography-related overdiagnosis and overtreatment picture was published within a week of the Scandinavian study. It involves DCIS, which was rare before mammography screening was introduced in the U.S., and now, more than 55,000 women receive this diagnosis yearly. DCIS has been variously called a precancer, a cancer, not a cancer, a high-risk factor. A survey published in the Journal of the National Cancer Institute showed that women are still given unnecessarily aggressive treatment for DCIS (e.g., mastectomy and removal of some of the lymph nodes at the armpit). Conversely, some are undertreated with excision alone for an uncommon type of DCIS called comedocarcinoma that will become invasive and therefore should be treated more aggressively (with radiotherapy).

What you can do:

If DCIS is diagnosed, it is advisable to get a second surgical opinion and a second pathology opinion (see below). With the exception of comedocarcinoma, pathologists are unable to identify which DCIS lesion will progress to invasive cancer and how long it will take to do so.

-To help you decide whether to have regular mammograms, go to this excellent decision-making Web site at the University of California, San Francisco www. mammography.ucsf.edu/inform/index.cfm

-Two of the country’s leading breast pathologists have long been working on ways to distinguish the forms of DCIS that will become invasive from those that will remain dormant. If diagnosed with DCIS, consider a second pathology opinion from Michael Lagios, MD, St. Mary’s Hospital, San Francisco (415) 789-0965 (www.breastcancerconsultdr.com), or David Page, MD, Vanderbilt University, Tennessee (615) 343-0072 (www. breastconsults.com). Both are breast pathologists who will deal directly with breast cancer patients.

Second Pathology Opinion for Early Breast Cancer

Why You Should Consider a Second Pathology Opinion for Ductal Carcinoma in Situ
By Maryann Napoli
(August 2003)

Ductal carcinoma in situ now represents one out of every five new cases of mammography-detected breast cancer diagnosed in the U.S. Despite its ominous name, which means cancer within the milk duct of the breast, DCIS is not always destined to become deadly. Only an estimated one-third of all cases will progress to invasive breast cancer, even if left untreated. The massive rise in DCIS is due to the increased acceptance of mammography screening. But the ability to diagnose DCIS has outpaced the knowledge of how to treat it without causing too much harm. A new study conducted in the UK, New Zealand, and Australia provides some partial answers (The Lancet, 7/12/03).

No cancer agency keeps track of how DCIS is treated in the U.S, but uncertainty is clearly reflected in the range of possibilities. This microscopic lesion can be treated with excision plus six weeks of radiation therapy, breast removal, or excision alone. There is also a great deal of uncertainty about the use of the anti-breast cancer hormonal drug tamoxifen following the initial treatment.

The new study conducted by the UK Coordinating Committee on Cancer Research set out to determine which treatment or treatment combination results in a lower rate of recurrence. All of the 1,694 participants had an excisional biopsy and were then given either no further treatment, radiation therapy, or tamoxifen, or both. The recurrence rate was lower in the women given radiation therapy, as compared to women treated with surgical excision alone. But the difference between the two groups was small:TInvasive breast cancer occurred in the affected breast of 2.5% of the women given radiation therapy, compared with 5.3% in the excision alone group.

The median follow-up for this study was only four years–too short a time to know whether radiation therapy actually extends life, or if the adverse effects of radiation itself outweigh the reduced chance of recurrence. (Earlier research showed a slight increase in cardiovascular deaths among younger women given radiation therapy.) This study will have the unfortunate effect of reinforcing the current “treat all to decrease recurrences in a tiny minority” approach to radiation. As for tamoxifen, the new study found little evidence to support its use.

Two of the country’s leading breast pathologists have long been working on ways to distinguish which forms of DCIS will become invasive and which will remain dormant. Consider a second pathology opinion from Michael Lagios, MD, San Francisco (415)789-0965 (www.breastcancerconsultdr.com), or David Page, MD, Vanderbilt University, Tennessee (615)343-0072 (www.breastconsults.com).
Both will deal directly with breast cancer patients.