Was Napoleon poisoned?

Some conspiracy theorists believe Napoleon Bonaparte was poisoned with arsenic 188 years ago.

After his defeat at the battle of Waterloo in 1815, Napoleon was exiled to St. Helena, an island in the South Atlantic Ocean. He died in 1821 at age 52. During most of his exile, Napoleon lived with a retinue of about twenty people who included some who had a motive for wanting to murder him. Even Napoleon was paranoid about his illness during the last months of his life. He specifically requested that an autopsy be performed on him in the event of his death with “particular focus” on what was in his stomach at the time of death. The autopsy report listed gastric cancer as the cause of death. But the rumors continued.

A number of Napoleon's staff had kept locks of the Emperor's hair, which were passed down the generations, sometimes coming up for auction. In the 1960s a Glasgow University forensic scientist Professor Hamilton Smith, who had developed the nuclear techniques to record very small levels of arsenic showed that small quantities of arsenic were present in Napoleon's hair. Thus the rumors continued that Napoleon had been murdered.

I just came across an article written by my good friend Dr. Genta, a Texas pathologist-gasteoenterologist. He and fellow researchers analyzed Napolean’s original autopsy reports, Napoleon's medical history, memoirs from his doctors and other documents.

Dr. Genta and Swiss and Canadian researchers decided to see for themselves, having been intrigued by the idea that Napoleon could have changed the history of our world by escaping exile. For their study, they relied on current medical knowledge and historical data.

The autopsy reports showed that Napoleon lost a lot of weight in his last months, a sign of severe illness. His stomach was filled with a dark material resembling coffee grounds, which indicated that gastrointestinal bleeding could have been the immediate cause of death.

Researchers compared the data with images of 50 benign ulcers and 50 gastric cancers. They concluded that Napoleon had a stage III gastric cancer, which today has less than a 50% survival rate of one year and less than 20% survival for five years.

"He was sentenced to death [by the cancer]," Dr. Genta said who also speculated that Napoleon likely had a history of chronic Helicobacter pylori gastritis, which probably increased his risk of gastric cancer.

Will Genta’s study finally let Napoleon rest in peace?
Doubtful. "The conspiracy theories will continue," says Dr. Genta.

If Napoleon had escaped and returned to power, his illness would have made for only a brief reign. "There was no need to poison him," Dr. Genta said. "He would have died in a short time."

So where did the arsenic in Napoleon’s hair come from? would’ve asked Dr. Watson

What was the name of the house lived in by Napoleon on St. Helena? replied the great detective.

It was Longwoood House. What has that got to do with it? responded the puzzled Watson.

Elementary my dear Watson, would’ve said Sherlock Holmes.

If you look at the decorating log of that house like I did you would see that the wallpaper of Napoleon’s bedroom was green. And in the weeks prior to Napoleon’s death the weather was hot and humid according an almanac of that day.

Scheele's Green was a coloring pigment that had been used in fabrics and wallpapers from about 1770. It was named after the Swedish chemist who invented it. The pigment was easy to make and was a bright green color but under certain circumstances the copper arsenite could be deadly. Napoleon’s wallpaper contained Scheele's Green which when it became damp and moldy in hot and humid weather, the mold could carry out a chemical process to convert the copper arsenite into a gas which would have been present in the hair of people who lived in the room.

REFERENCES
Jones, DEH, Ledingham, KWL "Arsenic in Napoleon's Wallpaper" Nature, Vol. 299 Oct. 14, 1982 p. 626-7.

BOTOX WARNINGS

Yesterday’s article dealt with illegal silicone treatments. Today we will mention the most popular “legal” cosmetic treatment – that of Botox.

You have probably read the news articles and perhaps heard rumors about recent Botox complications. While Botox is best known for clearing wrinkles by paralyzing facial muscles, the botulin-based drug also is widely used for muscle-spasm conditions. Botox and Myobloc, are designed to block nerve impulses to certain muscles, causing them to relax. Both drugs are approved to treat cervical dystonia, or uncontrolled muscle contractions of the neck and shoulder muscles.

In addition, Botox is approved for cosmetic use to treat wrinkles between the eyebrows and to help control excessive underarm sweating. Lower doses are used by professionals for cosmetic purposes than those used to treat limb spasticity.

In rare cases, however, the toxin can spread beyond the injection site to other parts of the body. This will cause paralyzing or weakening the muscles used for breathing and swallowing, a potentially fatal side effect.

Signs of botulism can appear just hours after injection and include
• difficulty swallowing or breathing,
• slurred speech and
• muscle weakness.

The FDA said it uncovered 225 cases of botulism related to the drugs during its analysis and 17 deaths for which its analysis seemed to suggest botulism as a cause.
Botox, Botox Cosmetic, and Myobloc are approved for "temporary improvement in the appearance of glabellar lines, treatment of strabismus, blepharospasm, cervical dystonia, and primary axillary hyperhidrosis.

An FDA statement, however, reassured the public. To date, none of the cases...reported have been associated with use of botulinum products in cosmetic or dermatological procedures, such as clearing furrows between the eyebrows, according to the FDA.

Indeed the FDA has just approved sales of new Botox like drug.

Ipsen SA and Medicis Pharmaceutical Corp. won US Food and Drug Administration approval to sell their product, Dysport [botulinum toxin type A], for both aesthetic and therapeutic uses. Like Botox [botulinum toxin type A], the new injection uses a type of botulinum toxin to relax the muscles that cause forehead lines and a neck-twisting disorder called cervical dystonia. The company will start selling the drug for aesthetic uses in the US within 30 to 60 days." Dysport injections may take effect more quickly than Botox, which typically takes three to 10 days before patients notice that wrinkles begin smoothing.

The FDA stated that even though "there have been reports of symptoms consistent with distant spread of the toxin effects following dermatologic use...no definitive serious adverse-event reports of this effect were associated with use of Botox at the labeled dose of 20 units for glabellar lines or 100 units for severe primary axillary hyperhidrosis."

How Should Botox be Given?

First make sure it’s given by a medical professional.

Botox parties given in peoples homes may be dangerous when given by non authorized personnel.

Patients should know that the practitioner must follow the FDA’s recommendations made in the 2008 Early Communication; that healthcare professionals who use botulinum toxin products should:

• Understand that dosage strength (potency) expressed in “Units” or “U” are different among the botulinum toxin products.
• Clinical doses expressed in units are not interchangeable from one botulinum toxin product to another.
• Be alert to and educate patients and caregivers about potential adverse events due to distant spread of botulinum toxin effects following local injections including:
• unexpected loss of strength or muscle weakness,
• hoarseness or trouble talking
• (dysphonia), trouble saying words clearly
• (dysarthria), loss of bladder control,
• trouble breathing,
• trouble swallowing,
• double vision, blurred vision and drooping eyelids.

Understand that these adverse events have been reported as early as several hours and as late as several weeks after treatment.

Patients must seek immediate medical attention if they develop any of these symptoms.

The FDA urges both healthcare professionals and patients to report side effects from the use of Botox and Botox Cosmetic (Botulinum toxin Type A), Myobloc (Botulinum toxin Type B), and Dysport (abobotulinumtoxinA) to the FDA's MedWatch Adverse Event Reporting program.

• online at www.fda.gov/medwatch/report.htm
• by returning the postage-paid FDA form 3500 available in PDF format at www.fda.gov/medwatch/getforms.htm to 5600 Fishers Lane, Rockville, MD 20852-9787
• faxing the form to 1-800-FDA-0178
• by phone at 1-800-332-1088


Please remember, as with all our articles we provide information, not medical advice.

For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

SILICONE WARNING. A Cheap, Fast and Possibly Deadly Route to Beauty

The New York Times documents that nationally, reports of buttock enhancement using silicone and similar thick liquids have surfaced from the Northeast to Miami.Across the Internet, chat rooms, Web sites and blogs have sprung up discussing buttock injections. The injections are administered at home, in motel rooms, in makeshift offices or at “pumping parties,” where the guests take turns injecting one another.”

In the last 10 months, New York City's health department-- the city's poison control center has received three calls...from doctors who have treated patients injected with silicone elsewhere."

This seems to be kind of an underground occurrence, so it's difficult to get numbers of actual events and to know exactly what these people are being injected with. ... It's important to note that none of the products that are reportedly being used are approved for this purpose.

Silicone was not approved for injection into tissues at all, only for use in the eyes and in certain implants where it is contained and cannot leak into tissue.The victims-usually women- may be unable to afford conventional plastic surgery and tap into it through unlicensed practitioners working through word of mouth and the internet.

The danger is that silicone can migrate through tissues, leading to ugly lumps and chronic pain as well as death if it migrates into vital tissue like lung and kidney. Industrial-grade silicone usually is bought at a hardware store. But there have been reports of the use of substitutes like castor oil, mineral oil, petroleum jelly and even automobile transmission fluid.

A Word of Warning on Cosmetic Surgery:

I recently read that “Hospital anesthesiologists were negligent in multiple cosmetic surgeries, causing three deaths”: A hospital and attending anesthesiologists have recently settled a malpractice lawsuit regarding errors during a face-lift procedure. A 56 year-old-woman died of cardiac failure caused by an overdose of local anesthetic. Alarms that monitored the woman’s blood oxygen “were accidentally turned down so that they were inaudible”. That same year, famous author Olivia Goldsmith died during cosmetic surgery at the prestigious hospital as a result of errors and still another woman suffered brain damage after a face-lift.

Even when performed by leading physicians the same risks of necessary surgery are not that much different than for other surgical procedures. One begins to think of a “nip and tuck” surgery with light humor. But when you review some of these reports you should realize you are taking a risk with any cosmetic surgery and should fully discuss this with your doctor.

In the next column we will deal with Botox warnings.

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

PART III of III: IN DEFENSE OF THE DOCTOR WITH A BAD REPORT CARD WHEN NOT ADHERING TO PAY FOR PERFORMANCE [P4P] GUIDELINES

PART III of III

The WSJ ran several letters received in response to Groopman and Hatzband alarming data- most from “quality professionals” pointing to 30 years of data in the Dartmouth Atlas showing widespread variation in the quality of care in many common chronic conditions. The Rand Corp statements that patients receive only about 56% of recommended care is also quoted. This widespread U.S. variation in healthcare is equated with low quality, injurious and costly medical care by these quality professionals instead of Groopman’s “what is best sometimes deviates from the norms.”

One letter writer from San Diego pathetically wrote that “Drs. Groopman and Hartzband state very well the dangers of general mandates in the practice of medicine. At our institution we are very concerned about the emergence of multi-drug resistant microbes, and we designed a treatment regimen for community acquired pneumonia to avoid certain antibiotics notorious for causing antibiotic resistance and Clostridium difficile infection. We were informed, however, that if we varied from the prescribed medication directive we would be out of compliance and suffer the consequences. Naturally, we caved to the pressure. Long-term consequences are not involved in the ‘metric.’"

But not answered adequately by these letter responses are the lack of outcome studies showing proof that the use of process quality measurements or metrics will improve morbidity or mortality in the real world. This unfortunately if addressed by the letter writers was not printed in the responses.

The devil in the details of “quality care” outlined by the letter-writing physicians is what the medical expert can use in his defense of the defendant physician “straying from the guidelines as we’ll see in a later chapter.

These devil in the quality details are:

• First, the federal incentive program entitled "pay-for-performance" is really "pay-for-process."
• Rather than measuring and rewarding improved outcomes, the program which is also being adopted by state and private insurers rewards adherence to practice guidelines.
• Second, there is little or no evidence the quality measures that comprise the guidelines correlate with improved outcomes, and
• If government and private insurers want to penalize and reward physicians for their practices they should measure those physicians' outcomes.
• This is dramatically demonstrated by the UCLA study mentioned above of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure.
  

One must agree that using quality guidelines seems like good thinking superficially, but these rigid rules cannot fit the complexity of the human condition.

I spoke about this matter with my good friend Dr. Bernie Rosof, a pioneer in the Quality movement about this controversy on P4P guidelines. He replied that

• These guidelines must be nimble, i.e. they must quickly change as the profession believes in a new guideline prompted by an appropriate study.
• In addition he believes that more recent guidelines should based on both process and outcome studies.
• And finally the new money on the health care scene will drive us to do more comparative studies to make sure the guidelines are appropriate and to drive down the high variability that is now the current scene in medical care.
  

What we need most are evidence based outcome studies showing the benefits of quality metrics on mortality/morbidity in concert with the application of such studies rather than experts getting together to hammer out compromised clinical practice guidelines as exists today.

Until such time my opinion as a medical expert based on a reasonable degree of medical probability is that a good defense can be offered to a physician defendant on an individualized basis.

REFERENCES:

Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com


Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
(Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com

PART II of III: IN DEFENSE OF THE DOCTOR WITH A BAD REPORT CARD WHEN NOT ADHERING TO PAY FOR PERFORMANCE [P4P] GUIDELINES

PART II of III

In summary this previous outcome study on Diabetes showed that:

1) patients with type 2 diabetes and no symptoms of coronary artery disease derive little benefit from screening for inducible myocardial ischemia,

2) based on a study of 1100 patients aged 50 to 75 with type 2 diabetes and without CAD symptoms.

3) During 5 years' follow-up, the incidence of the primary endpoint — a composite of nonfatal myocardial infarction and cardiac death — did not differ between the groups (about 3% in each).

4) Among screened patients, moderate or large perfusion defects were associated with greater risk for coronary events, but, the authors point out, only 12% of patients with such defects had an event (positive predictive value, 12%).

5) The authors thus conclude that routine screening for CAD "cannot be advocated" for asymptomatic patients with type 2 diabetes.

Before this study was complete arguments would rage about which technologies was cheaper (or in insurance company lingo) more cost effective to rule out coronary disease in diabetics. Experts would debate the armamentarium of technologies and after a prolonged discussion would come up with a workup process which would be adopted as P4P guidelines for the treatment of asymptomatic diabetics. With this outcome study, however, we see that routine screening for CAD "cannot be advocated" for asymptomatic patients with type 2 diabetes in the first place. Only an outcome study; not a process study can determine this conclusion.
Dr. J. Groopman whom we discussed in our books on Medical Expert Testimony –see references below-in the chapters on how doctors make mistakes, has joined a colleague Harvard professor Dr. P. Hartzband to proclaim [4/8/09 WSJ] that “buoyed by some successes on patient safety, public health care measures that governmental and private insurance regulators now have overreached.”

Soon they point out all Medicare payments will be tied to "quality metrics." Specifically in "pay-for-performance [P4P] programs, "private insurers define quality as clinical practice that conforms to consensus guidelines written by experts. These guidelines present specific "quality metrics" for physicians to meet in order to get fully paid.

In too many cases, they complain, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients.

In fact in Massachusetts, known snidely by their practicing doctors as the “People’s Republic of Massachusetts” physicians who “fail to comply with quality guidelines from certain state-based insurers are publicly discredited and their patients required paying up to three times as much out of pocket to see them report the authors.
They have turned clinical guidelines for complex diseases into ironclad rules, to deleterious effect,” say Groopman and Hartzband.

As examples of poor and misguided “quality” guidelines that turned out to be dangerous to patients, Groopman and Hartzband point to:

• The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric a tight control of blood sugar. However, this approach was turned on its head when the New England Journal of Medicine published a randomized study, of more than 6,000 critically ill patients in the ICU. More patients died in the tightly regulated group than those cared for with a more flexible protocol.

• Indeed, in one study of more than 10,000 ambulatory diabetics with cardiovascular diseases conducted by a group of researchers (the "ACCORD" study) so many diabetics died in the group where sugar was tightly regulated that the researchers discontinued the trial 17 months before its scheduled end.

• Another clinical trial contradicted another expert consensus guideline that patients with kidney failure on dialysis should be given statin drugs to prevent heart attack and stroke.

• Doubts about the relevance of quality metrics to clinical reality are even emerging from the federal pilot programs launched in 2003. An analysis of Medicare pay-for-performance for hip and knee replacement by orthopedic surgeons at 260 hospitals in 38 states showed that conforming to or deviating from expert quality metrics had no relationship to the actual complications or clinical outcomes of the patients.

• Similarly, a study led by UCLA researchers of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure.
These so called quality metrics which are the foundation of P4P guidelines, according to Groopman and Hartzband “are no substitute for a good doctor who exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what quality care is for the individual patient. Moreover, “what is best sometimes deviates from the norms.”

REFERENCES:
Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com

Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
(Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com

PART I of III: IN DEFENSE OF THE DOCTOR WITH A BAD REPORT CARD WHEN NOT ADHERING TO PAY FOR PERFORMANCE [P4P] GUIDELINES

Doctors suffer bad report cards by medical insurance carriers for not adhering to “quality of care guidelines.”

Doctors say these guidelines are more cost saving/profit making for the insurance companies than medical quality.

Who is correct?

Currently less than one tenth of 1% of the total. $2 trillion spent annually on health in the United States is spent on evidence based medicine to ascertain and establish competent medical clinical guidelines.

The demand for better evidence to guide healthcare decision-making is growing rapidly due to the variation of healthcare interventions, the frequency of medical errors, and the adverse consequences of care administered without adequate evidence.

The Roundtable on Evidence-Based Medicine in the office of the Institute of Medicine [IOM] have set a goal that, by the year 2020, ninety percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence on what works best for whom, and under what circumstances. http://www.iom.edu/CMS/28312/RT-EBM/55282.aspx.

To this end the American Recovery & Reconstruction Act of 2009 commits $1.1 billion to Comparative Effectiveness Research, and $19 billion to increasing health information technology.

Let’s look at an example of what such studies would look like in patients. --In this instance patients with Diabetes.

Almost 200 million people worldwide have type 2 diabetes. Coronary artery disease (CAD) is a major health concern and the leading cause of death in individuals with type 2 diabetes. CAD is often asymptomatic in these patients until the onset of myocardial infarction or sudden cardiac death. Type 2 diabetes is also widely recognized as a CAD risk equivalent. Thus endorsed by professional organizations screening of patients with type 2 diabetes and no symptoms of CAD were recommended in the absence of prospective outcome studies supporting its utility. Screening for CAD in patients with type 2 diabetes especially with 2 or more cardiac risk factors, though not an evidence based recommendation like many such guidelines had been also endorsed previously by an expert panel of the American Diabetes Association.

The strategy of routine screening for CAD in patients with type 2 diabetes is based on the premise that testing could accurately identify a significant number of individuals at particularly high risk and lead to various interventions that prevent cardiac events. However, in a study by Young L.H.et al, Cardiac Outcomes After Screening for Asymptomatic Coronary Artery Disease in Patients With Type 2 Diabetes;The DIAD Study: A Randomized Controlled Trial .JAMA. 2009;301(15):1547-1555 the results of the DIAD study would appear to refute this notion.

Although type 2 diabetes is considered to be a CAD equivalent participants had a low cardiac event rate (average, 0.6% per year) and the identification of participants with abnormal screening results did not serve to eliminate their risk over 5 years of follow-up.

The current standard of care for type 2 diabetes emphasizes the reduction of cardiovascular risk factors. However, there has also been substantial interest in the early detection of asymptomatic CAD by screening of patients with type 2 diabetes. Recent studies have shown that CAD can be detected noninvasively in a significant number of these individuals. Inducible ischemia and coronary artery calcium each have been shown to be associated with worse cardiac outcomes. However, the potential of routine screening to alter treatment and to prevent cardiac events in persons without clinically apparent CAD is largely unknown.

Thus, although endorsed by some professional organizations, screening of patients with type 2 diabetes and no symptoms of CAD remains highly controversial in the absence of prospective outcome studies supporting its utility.

In the light of the author’s findings, routine screening for inducible ischemia in asymptomatic patients with type 2 diabetes cannot be advocated for 4 reasons.

• First, the yield of detecting significant inducible ischemia is relatively low.
• Second, the overall cardiac event rate is low. Indeed, even our participants with moderate or large defects and the highest event rate would be conventionally assigned to an intermediate-risk category.
• Third, routine screening does not appear to affect overall outcome.
• Finally, routine screening of millions of asymptomatic diabetic patients would be prohibitively expensive.

MAMMOGRAPHY-DIFFERENT AFTER AGE 65? – FULL DISCLOSURE: PART II of II

Many of my GI patients and friends retired to South Florida have asked me to research the use of Mammography in women past the age of 65 so they can make informed decisions with their personal and family doctors.

First we should realize that more than half of the cases of breast cancer treated in the United States occur in women over age 65. Yet mammography screening for older women is controversial, because no good randomized trials [prospective evaluation of a control vs. an experimental population] of such screening have been conducted in older populations.
This is what I researched for them.

Bottom Line: Effectiveness was modest and false positives were common. But there are pros and cons which I present here to augment full and informed decisions with their personal physicians.

CONS:
In the one prospective cohort study from three outpatient clinics in Boston, [Published in Journal Watch General Medicine April 30, 2009[Schonberg MA et al. Weighing the benefits and burdens of mammography screening among women age 80 years or older also J Clin Oncol 2009 Apr 10; 27:1774], researchers tracked mammography screening and breast cancer outcomes in over 2000 women (age, 80 at the beginning of the observation period) and who were followed for 2 to 12 years (median, 5 years).

Half the women underwent mammography (average, about 2.5 mammograms per screened patient), and half did not. Twenty-eight breast cancers (including 8 ductal carcinomas in situ) were diagnosed among mammography recipients, and 20 were diagnosed among women who did not undergo mammography (half by clinician exam and half by patient-reported symptoms or signs).

Breast cancer that was diagnosed during the study interval caused one death in the mammography group and two deaths in the no-mammography group.

According to the J Clin Oncol. 2009 Apr 10;27(11):1774-80. Epub 2009 Mar 2, among screened women, 11% have false-positive mammograms that results in additional imaging tests or biopsies. Conclusions reached by the authors are that the majority of women > or = 80 years are screened with mammography yet few benefit.

Meanwhile, 12.5% experience a burden [extra tests, some invasive] from screening.
Because this study was small and because these women were not randomized, it cannot serve as a general rule of mammographic screening in the older woman. But it does suggest that the effectiveness of mammography is modest at best among women in their 80s and that the false-positive rate is not trivial in this age group. False positives you know lead to more aggressive and sometimes dangerous follow-up tests.

How about the issue of Mammography in older frail women?

Walter and Covinsky [J Gen Intern Med. 2001 Nov;16(11):779-84.] concludes that screening mammography in frail older women frequently necessitates work-up that does not result in benefit. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.

PRO Mammography in the Older Woman

McCarthy EP, et al. from Harvard [J Am Geriatr Soc. 2000 Oct;48(10):1226-33.Mammography use, breast cancer stage at diagnosis, and survival among older women. ] showed that women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Older women the authors say who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. Their data support the use of regular mammography in older women at least those age 65 and suggest that mammography can even reduce breast cancer mortality in older women, even for women age 85 and older.

[Cancer. 1996 Dec 15;78(12):2526-34.The influence of risk factors on breast carcinoma screening of Medicare-insured older women. National Cancer Institute Breast Cancer Screening Consortium.] Roetzheim R, et al selected women to undergo mammography based on risk factors in women age 65 years or older). These risk factors included women with a family history of breast carcinoma and women who have had incidental radiation exposure of breast tissue which significantly increases the risk of breast cancer. The authors concluded that older women with additional risk factors should more likely to undergo screening mammography and that interventions that target older women with risk factors and their physicians thus appear warranted.

[J Clin Oncol. 2007 Jul 20;25(21):3001-6. Epub 2007 Jun 4. Mammography surveillance and mortality in older breast cancer survivors.] Lash TL et al. performed a large observational study which provides support for mammography in older women aged 65 and older and appears reduces the rate of breast cancer mortality in older patients diagnosed with early-stage disease.

[Breast Cancer Res Treat. 2008 Oct;111(3):489-96. Epub 2007 Oct 24.Surveillance mammography and the risk of death among elderly breast cancer patients.]
Schootman M et al examined the benefits of mammography for elderly breast cancer survivors in community settings. He found that among 1351 breast cancer deaths (cases) and 5,262 controls, women who had a mammogram during a one or two-year time interval were less likely to die from breast cancer than women who did not have any mammograms during this time period. Similarly, risk of all-cause mortality was reduced among women who had mammograms during one- or two-year intervals. They concluded that in community settings, mammography use during a one- or two-year time interval was associated with a small-reduced risk of breast-cancer-specific and all-cause mortality among elderly breast cancer survivors.

My opinion about mammography in the older woman?

Finally we should know this. There are attitudinal differences by medical providers in the diagnosis and treatment of breast cancer in women over 65.

A retrospective review of all women with primary operable invasive breast cancer treated at the University of Michigan Breast Care Center over a 30-month period was reviewed in the [Ann Surg Oncol. 1994 Jan;1(1):45-52. Age-related differences in breast cancer treatment.August DA et al.from the Department of Surgery, University of Michigan, Ann Arbor 48109-0331.]
This was a study of a total of 77 older patients aged > or = 65 years (median, 71; oldest patient, 92). Fifty-one similar younger patients aged 55-64 years (median, 59) were identified for comparison.

Patients were classified as either having received standard treatment or non-standard treatment. When overall treatment (local/regional plus systemic) was assessed, proportionately fewer older patients received standard treatment. Overall, only 59 of 77 older patients versus 50 of 51 younger patients received standard local/regional care.
Older patients were less likely to receive chemotherapy than younger patients (7% versus 50%; p < 0.001). “Interestingly,” say the authors, “explanations for decisions to deviate from standard treatment guidelines were often not identified.”

These data demonstrate age-related variations in breast cancer treatment in a multidisciplinary breast care unit. Although good clinical judgment may have played a role in these differences, via age-related patient preferences and co-morbidity, “the age-related attitudes of caregivers must also be taken into account to fully explain these variations,” state the authors.

In conclusion, after I go through a full discussion with patients listing all the pros and cons I’m then almost always asked this question? Dr. Hookman-That’s all well and good-but what would you suggest if I was your sister?

My answer is always that each case has to be individualized to your medical history, your risk factors, you physical exam, you routine lab data-even your anxiety level etc.
But all the above factors being considered and evaluated I would go ahead and recommend annual to biannual mammograms in patients over 65-especially with increased risk factors enumerated above, and be wary of any attitudinal difference in medical provider behavior towards older patients.

Please remember, however, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s].
These articles are not to be taken as medical advice for you.