New guidelines for screening mammograms and PAP smears were just released.  As with all healthcare issues, the best decisions are made by the individual patient and her physician.

Screening Mammograms

On November 16, 2009, the U.S. Preventative Services Taskforce (USPSTF) issued new guidelines for screening mammograms. The USPSTF recommended against routine screening mammography in women 40- to 49 years, biennial screening for women between the ages of 50 and 74 years, had no recommendations in women 75 years or older. The USPSTF recommended against physicians teaching women how to perform breast self-examination. On November 18, 2009, Health and Human Services Secretary Kathleen Sebelius stated the federal guidelines on routine breast cancer screening would not change as a result of the USPSTF guidelines. The current guidelines by the American College of Obstetricians and Gynecologists, The American College of Surgeons, and The American Cancer Society are that women obtain yearly mammograms beginning at age 40.

Breast cancer is the second most frequently diagnosed cancer in women in the United States, following skin cancer, and is second to lung cancer as a cause of cancer deaths. The National Cancer Institute estimates the lifetime risk in women for breast cancer is 12%. The 10-year risk for a woman at age 40 is 1 in 69, at age 50 is 1 in 42, and at age 60 is 1 in 29. If you happen to be the 1 in whatever number, statistics do not matter.

So, “what is a girl to do?” A few comments about the new USPSTF guidelines are appropriate. The guidelines are only that- guidelines. Each patient should be treated as an individual. Multiple factors should be considered when making a decision about healthcare including (but not limited to): family history, personal risk factors, other medical problems, anxieties, and ability to pay. (My personal feeling is that effective healthcare reform should eliminate the ability to pay as a factor to consider.) Just as the Administration and Congress are not effectively addressing the root causes of escalating healthcare cost such as the effect of our legal system, advertising by drug and medical product manufacturers,  and administrative costs, our healthcare system does not effectively address many issues that could reduce disease, pain, and suffering – and cost! One example is the effect of obesity on the risk of disease including cardiovascular disease (heart attack and stroke), diabetes, and even cancer. Every year, 40% of uterine cancers, 35% of esophageal cancers, 28% of pancreatic cancers, 21% of gallbladder cancers, 17% of breast cancers, and 9% of colorectal cancers are linked to excess body fat.

Bottom line, I continue to recommend yearly mammograms beginning at age 40 with the agreement of the individual patient. On occasion a patient should get an initial screening mammogram at age 35, and sometimes earlier depending on individual factors such as family history. Breast self-exam has the potential for finding breast cancer and should be done monthly and started in the 20’s so a woman learns what is a “normal breast exam” for her. Occasionally, MRI is appropriate, again depending again on individual factors.

PAP Smears

The American College Of Obstetricians and Gynecologists (ACOG) has recently issued (December 2009) new guidelines for PAP smears in women. Again, these are guidelines and should be considered on an individual basis. Regardless of the frequency of PAP smear screening, annual gynecologic examinations are frequently appropriate even if PAP smear is not performed at each visit. Many other healthcare concerns can be addressed including (but not limited to): menstrual complaints, pelvic pain, STD’s, breast health, high blood pressure, weight issues, sexual health, fertility concerns, contraception, PMS, and emotional questions.

The American Cancer Society estimates 11,270 new cases of cervical cancer in the United States in 2009 with 4,070 deaths from the disease. Fortunately the rate of cervical cancer has decreased from 14.8 per 100,000 women in 1975 to 6.5 per 100,000 women in 2006 in the United States. It should be noted that no screening procedure including both the PAP smear and the mammogram are perfect – there are false positive and false negative results. Technology has helped reduce these errors.

Infection with high-risk human papillomavirus (HR HPV) is necessary for the development of cervical cancer, but most HPV-infected women will not develop cervical cancer. HPV infection is readily transmitted during sexual intercourse. Many women, especially younger women, clear the infection within 8-24 months due to an effective immune system. Cigarette smoking and a compromised immune system (such as with HIV infection) appears to affect the ability to clear the infection. The vaccine targeting HR HPV-16 and 18 (in addition to two low-risk HPV types) may help further reduce the rate of cervical cancer. The vaccine is recommended for women 9-26 years of age, and these women should have PAP screening identical to those who have not received the vaccine.

The following are the current recommendations for PAP screening (December 2009):

· PAP screening should begin at age 21

· PAP screening is recommended every 2 years for women between ages of 21 years and 29 years

· PAP screening for women 30 years and older may extend the interval to every 3 years if:

o   They have had three consecutive negative PAP smears

o   They are HPV negative on the last PAP smear

o   They have no history of CIN2 or CIN3 (moderate dysplasia or worse)*

o   They are not HIV infected or immunocompromised**

o   They were not exposed to diethylstilbesterol (DES) in utero***

· PAP screening for women who have had a total hysterectomy for non-cancerous reasons and who have no history of CIN2 or CIN3 (moderate dysplasia or worse) can be discontinued

*dysplasia means abnormal growth of cells, in this case in the cervix – another term used in describing abnormal PAP smears is cervical intraepithelial neoplasia or CIN – in both classification systems there are varying degrees of abnormality from mild to severe or CIN1 to CIN3 – abnormalities up through CIN3 can be removed by simple excision – invasive cancer must be treated with more extensive surgery and/or radiation

**immunocompromised refers to people having conditions that result in a decreased ability to fight infection and other disease

***diethylstilbesterol (DES) is an estrogen was thought to be safe and to reduce the chance of miscarriage – it was shown to increase the risk of vaginal cancer in the female babies of mothers who took the drug during pregnancy  – the drug was taken off of the market in 1971

In conclusion, advances in medicine are being made every day, including recommendations for screening, diagnosis, and treatment. What is best for you should be a decision that you and your physician make on an individual basis.

In The Kitchen With Dr. B. – Delicious Mashed Potatoes

With the holidays rapidly approaching, this is one recipe that will have all coming back for seconds. A word of caution, this is not a healthy dish because of the saturated fat content! Therefore I fix it only occasionally – the word is moderation in quantity and frequency. Many years ago a friend and chef extraordinaire, Gerry Klaskala, prepared a meal for a small gourmet club. This was one of the items in the feast. By the way, Gerry was the original chef of 45 South here in Savannah and of Buckhead Diner and several other restaurants in Atlanta.

· ¼ pound celery root (knob), peeled and diced into 1 inch dice

· 4 pounds potatoes, peeled and diced into 1 inch dice

· 1 pint heavy cream 

· ½ pound unsalted butter  

· Salt and white pepper to taste   

Celery root can be found in many well-stocked produce sections. It looks like a round potato or turnip root and weighs about 1 pound when peeled. The diced celery root should cover most of the bottom of the sauce pan and should be just covered with water. If too much water is used, this will leach the flavor out of the diced root. Cook in boiling water until very tender – tested with a sharp knife. Do not cook too long; this will change the flavor – the same thing applies to the potatoes. Puree the celery root in a food processor or blender.

Cover the potatoes with water in a deep sauce pot, add salt, bring to a boil, and simmer until quite tender. Drain and place in a mixing bowl and whip until half smooth. After adding the celery root puree, the 2 ingredients will be whipped again – if the potatoes are over-whipped, they will become rubbery.

Bring the cream and butter to boil and add to the potatoes. Add the celery root puree and whip until smooth. Season with salt and white pepper. This can be placed in a double-boiler to keep warm for several hours, but do not let it get too hot or this will change the flavor. I do not frequently recommend specific brands or stores, but I use Diamond Crystal kosher salt almost exclusively in cooking because of its texture and taste (this was a hint given by a local professional chef). When using kosher salt, it takes about twice as much to get the same degree of saltiness as regular table salt. Also, you should be aware this salt is not iodized, and if you had no other source of salt you could develop an iodine deficiency.

If you would like a healthier version, use red skin (new) potatoes, eliminate the cream and butter, and substitute skim milk and/or chicken broth. The potatoes can be used skin-on, washed before dicing. Enjoy!

The Staff and I at Advanced Healthcare for Women wish you all a happy, healthy, and safe holiday season.