The Medical News Report
Samuel J. LaMonte, M.D., FACS
Happy New Year 2019
I wish you great health and happiness for 2019. May your families and friends have healthy New Year’s Resolutions and pray for peace and civility in our wonderful country and the world!
Subjects for January, 2019
IMPORTANT REMINDER!!!! PLEASE READ!!!
I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.
The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns. You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.
Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.
Also remember the holidays can be stressful and heart attacks are more common this season than any other time of the year.
Thanks!! Dr. Sam
I have discussed various aspects of Medicaid and how the costs continue to rise exponentially thanks to a variety of factors including massive immigration over the last decade, benefits from expanded Medicaid in many states and welfare benefits that diminish the incentive to find low paying work, and the fraud that is occuring!
There are 11 states (2010) that are considered “welfare” states because they actually have more of the adult population on welfare than work. This includes food stamps, welfare checks, free social services, and Medicaid. I wonder how many more have been added since then?
In 2012, the Senate Budget Committee reported that the U.S. Household below the poverty level (about $33,000) received food stamps, housing support, care, Medicaid, and other support worth $168 dollars a day, while the average family makes $50,000 a year, which works out to be $137.13 a day. In other words, that works out to $30.00 an hour for a 40 hour work week, while the average job pays $24.00 an hour. Where is the incentive to work??
We are on our way to a socialist welfare country before your very eyes.
New Mexico leads the country in being most federally dependent. Note this is a border state. Following N.M. is Kentucky, Mississippi, Alabama, and West Virginia.
Most of my readers are not on Medicaid, but be rest assured, you are paying for it, and should be knowledgeable about where our money is going. When those on welfare outnumber those who work, what kind of government do you think they will vote for?
Some states require recipients to work to qualify for Medicaid. Several states have proposed work requirements to be eligible for Medicaid benefits. Kentucky already has an established requirement, and 8 other states (Ark, Ariz, New Hamp, Maine, Utah, Kan, Ind, and Wisc.) are proposing legislation. This will not only be great news for lowering costs, but will encourage people to get to work and be able to afford their deductibles and copays.
Bipartisan support for Medicaid reform is mandatory. With the economy improving, there is hope. Government will never get out of the healthcare policy business, but getting a handle on reform and cost is a must, and states need to try and come up with more uniform policies. NEJM, Dec. 6, 2018
Medicaid fraud is a serious expensive problem. It is defined as billing for payments to Medicaid for drugs, services, and supplies that is intentionally or knowingly false. Billions are spent in paying for fraudulent claims and people who do not qualify for benefits. Lying to the government has become an art form!
The Washington Times in December, 2018 reported that Louisiana found in an audit that 82 out of 100 receiving benefits under expanded Medicaid made too much money to qualify for Medicaid, while the state is spending $12.4 billion on Medicaid representing 36% of their state budget. You recall that all but 11 states expanded Medicaid during the Obama administration.
Three types of fraud—provider, patient, and insurer fraud
1- Providers frequently bill for services not performed, falsify a diagnosis, order excessive tests, and prescribe medications that are not medically necessary.
2- Patients are known to file claims for services not rendered, forge or alter receipts, obtain medications and sell them, providing false information to apply for services, falsify claims that a person is a caregiver for a disabled person, and use someone else’s insurance coverage for services.
3- Insurers overstate their costs for services, mislead enrollee’s health plan benefits, undervalue the amount owed by the insurer to a healthcare provider, and deny health claims that are justified.
5 Examples of fraud that will shock you!!
1- In 2014, 107 healthcare providers including doctors and nurses were arrested for defrauding Medicaid for $452 million in funds.
2- Russian and Nigerian mobs moved to Florida from New York, because it was so much easier to defraud Medicaid than other organized crimes.
3- California, New York, Texas, Kentucky, and Ohio had the greatest number of fraud cases.
4- Medicaid fraud costs the government as high as 1.5% of their revenue compared to 0.05% of credit card fraud.
5- Home healthcare visits and durable medical equipment (wheel chairs, walkers, breathing machines,etc.) accounts for a significant amount of the fraud because it is so hard to track.
For 20 more examples of outrageous fraud, click onto the website
Combating Medicaid (Medicare) Fraud and the cost
I am unable to find a statistic for the cost of fighting Medicaid fraud, but it is certainly in the millions. This has become a serious issue that must become a mission for our current administration. As our government tries to curtail healthcare costs, this is but one more issue that must be hit head on with more stiff penalties, fines, and imprisonment. The world of ethics and professionalism is slipping away in this dog-eat-dog world.
Medicare fraud is the same as Medicaid only worse….$75-250 billion, according to bankrate.com.
Whistleblowers are encouraged to notify authorities about fraudulent practices. There are numerous websites to report Medicaid and Medicare fraud, but I would go to and search for reporting fraud.
Yes!! It is real! The Mayo Clinic provided a nice summary on this syndrome. There are more heart attacks during the holidays than any other time of the year because of the stress surrounding holidays, family, and friends.
This is a temporary condition brought on by a stressful situation, such as death of a loved one. People with this issue may think they are having a heart attack with sudden chest pain.
In this situation, there is a temporary disruption of the heart’s normal pumping function of part of the heart muscle with the rest of the heart normal. The heart is reacting to stress hormones. There are many names for this syndrome including stress (Takotsubo) cardiomyopathy. If pre-existing heart disease is present, this could be extremely hazardous.
At Rice University, they found that losing a loved one (especially a spouse) caused enough stress to raise multiple inflammatory markers (cytokines) to cause heart damage and even heart failure. Long term effects cause hypertension which increases the risk of stroke and heart attack from rupture of plaque in the coronary artery wall.
Symptoms include chest pain and shortness of breath. It is scary and if there is any question about this being a real heart attack, call 911. Stressful situations can often bring on actual heart attacks.
Most everyone is familiar with the flight or fight hormones. Adrenalin can be secreted by the adrenal glands and give a surge in heart rate, blood pressure, and prepare for an urgent situation. Adrenalin is the stress hormone but there are others including corticosteroids.
Release of these adrenal hormones and adrenalin just mentioned also occurs in patients with PTSD, and patients who are grieving also are at risk for PTSD, which has now been shown to increase the risk of cardiovascular events by as much as 50%. PTSD also can occur in the aftermath of a cardiovascular event. All of these disorders have a common theme—psychosomatic consequences. Lancet, Jan., 2017
These hormones can cause a temporary constriction of blood vessels and cause symptoms of angina which can lead to a heart attack.
There are numerous conditions that can bring on this syndrome including news of an unexpected death, a frightening medical diagnosis, extreme anger, domestic abuse, losing or even winning a large sum of money, a strong argument, a surprise party, having to perform publicly, a sudden job loss, or divorce, or a sudden stressful situation such as surgery, a car accident, or an asthma attack.
Certain drugs may contribute to this syndrome including adrenalin, Cymbalta (an anti-depressant), Effexor (another anti-depressant), and levothyroxine (Synthroid).
Risk factors may include being female (more often than males), age (usually occurs after the age of 50), a history of a neurological conditions (those with a history of head injury, or a seizure disorder), and those with chronic anxiety or depression. If a person experiences this syndrome, it may increase the likelihood of a future event if another stressful situation occurs.
Stress is the number one killer, and most diseases are either partially responsible for or aggravated by stress. It is well known that stress reduces the effects of the immune system, lowering the normal body’s resistance to develop infection, cancer, heart disease, immune-related diseases, etc.
When an acute stress occurs, the body’s ability to withstand the flooding of adrenalin into the blood vessels will determine what physiologic events might occur.
Learning to cope with stress, both acute and chronic, is critical in this crazy world we live in. Coping mechanisms include outlets for stress including exercise, yoga, meditation, deep breathing, and listening to music, avoiding people who are always “stirring the pot”, politics, conflicts with family, friends, and associates, etc.
If a person has trouble coping or has signs of anxiety or depression, medication and counseling is suggested.
If a person has experienced this syndrome, they should see their doctor for a workup to rule out actual heart pathology.
There are situations that people just give up the will to live. An article by UK professor John Leach PhD reported on prisoners of war and sea survivors who were healthy and died of no known cause. He theorized there were 5 progressive stages people that give up experience:
1) social withdrawal 2) apathy with lack of motivation 3) aboulia defined as dampening of emotional response, inability making decisions, and loss of speech inititative with “brain fog” 4) psychic akinesia with indifference to pain, hunger, or thirst with little motor activity 5) psychogenic death. He theorized that this progression was associated with dopamine dysfunction (a neuroreceptor).
These patients can be saved with adequate psychologic and pharmacologic intervention. Also survival training in the military is vital to educate those who get in harm’s way can cope. Much needed research will help understand this phenomenon. Medscape as reported in the journal Medical Hypothesis, 2018
Treatment of an event such as broken heart syndrome is similar to treating a potential heart attack. If a patient goes to an emergency room, the patient will probably need to be monitored at least over night in the hospital.
Medication that can be given to lighten the load on the heart include diuretics, and anti-hypertensive meds (beta blockers, ACE-inhibitors) to help the heart to work more efficiently.
It may take as long as a month to overcome this syndrome if it is severe. Dealing with the underlying reason for the syndrome must be addressed whether it is going through severe grief, acute stress, or desperation, and despair, behavioral psychotherapy is effective in any situation that points to a psychosomatic cause of a cardiovascular event, whether a patient with the broken heart syndrome or PTSD.
Mayo Clinic Housecall, April 30, 2018
Medscape Medical News, October, 2018
This issue is a huge problem that should be screened for by primary care physicians, and all physicians who either treat patients with diseases that alter the normal sex drive, aggravate satisfactory intercourse (including achieving orgasm), aggravate or create impotence, or make pregnancy either difficult or impossible. Too few doctors discuss sexual dysfunction with their patients who are frequently reluctant to bring up the subject.
Causes of sexual dysfunction
There is a large list of diseases that interfere with sexual dysfunction by interfering with certain pelvic neurologic functions. Outside of stress, diabetes may be the most common disease causing this problem, because diabetes is a neurovascular disease and interferes with the nerves and blood supply to the genitals. One study reported that 1 out 3 diabetic women cannot achieve orgasm because of clitoral neuropathy with decreased sensation.
In fact, many neurological diseases cause sexual issues that include spinal damage with paralysis, multiple sclerosis, etc., patients with certain vasculopathies, patients on chemotherapy, surgically induced menopause, prostate cancer treatments, and many medications that interfere with libido such as anti-depressants (SSRIs), prostate medications, anti-hormone medications after prostate or breast cancer therapy to prevent recurrence, to name a few. Menopause with lack of estrogen causes dryness of the vagina and painful intercourse. Probably psychological disorders create more sexual dysfunction than neurologic ones.
In women, orgasm requires a coordinated effort from the neurologic and vascular system including the pelvic musculature to achieve adequate lubrication and clitoral enlargement to achieve enjoyable intercourse and orgasm. Uterine fibroids, pelvic inflammatory diseases with scarring, and endometriosis can all cause painful intercourse.
In men, erection must be achieved with increasing sympathetic nervous system to dilate the blood vessels of the penis, normal sensation, and input from the psyche. Any disease that interferes with any aspect of these systems can prevent successful sustained erection with enjoyable intercourse and normal orgasm.
Vibrators as a means of achieving orgasm was reported at the 2018 American College of Obstetricians and Gynecology annual meeting by Dr. Lauren Streicher from Northwestern University at Evanston, Illinois. She emphasized that doctors must ask patients about achieving satisfactory intercourse including orgasm and the use of vibrators for women. In her study, she reported that half of women use vibrators and those who are embarrassed to use them should be encouraged to give it a try to achieve clitoral orgasm during intercourse or by themselves.
Sexual counseling, psychotherapy, the use of hormones for women and men, penile stimulants (vacuum devices, Cialis, Viagra, penile implants, penile injections (or suppository)--Alprostadil, and pelvic floor physical therapy (Kegel exercises) all must be discussed or the patient should be referred to specialists who can address these options. There are natural supplements that promote improving ED, but in fact, have stimulants that are illegal such as Viagra. A thorough evaluation of medical and or psychological issues is a must.
Strick management of diabetes may help, but those with neurovascular disease may likely need further help.
Smokers are twice as likely to have ED! Stop smoking.
Preserving female eggs and male sperm prior to cancer treatment should be discussed in those who might want to conceive at a later date. Certainly this discussion must occur prior to cancer therapy.
There is a specialized ED surgery to improve the blood flow to the penis to create and maintain an erection. Female surgical procedures (remove fibroids, endometriosis, etc.) with hormonal replacement may be valuable.
There are clinics that specialize in this subject. Ask your doctor for a referral. WebMD, Medicine.net
Patients who suffer from the galaxy of symptoms of this syndrome have been diagnosed as hypochondriacs, malingerers, drug abusers, crazy, and undiagnosable. It was not many decades ago that chronic fatigue syndrome and fibromyalgia were not considered true entities. Thankfully, over the years and much research, it became clear these patients were dealing with real symptoms from an unknown cause.
I have written about chronic fatigue syndrome:
I have also reported on fibromyalgia:
There is a new term that is now recognized for a constellation of disorders that includes fibromyalgia, chronic fatigue syndrome, and many other neurological disorders that have common symptoms regardless of the cause especially pain. It is called Central Sensitivity Syndrome (CSS).
Pathophysiology of the Nervous System in CSS
Central sensitization was discovered performing neurobiological experiments in the laboratory in London, England in the early 1980s by stimulating nerves and measuring their response. It can be induced in humans by using various stimuli and chemicals introduced through the skin. Once these pain fibers are damaged, the pain persists and may be permanent.
Recent research indicates there is brain inflammation in patients with fibromyalgia which is one more indication that this is a legitimate disease. Medscape Medical News, November, 2018
Defining this syndrome (CSS)
This syndrome is defined as a condition of the central nervous system (CNS) that is associated with the development and maintenance of chronic pain. When the CNS is affected by often unknown causes, it gets regulated into a state of hyperexcitability. This lowers the threshold for pain and is maintained even after the cause has passed (if known).
This neurologic phenomenon creates 2 common symptoms—allodynia and hyperalgesia. Allodynia is defined as a heightened sensitivity to pain, and hyperalgesia is an amplification of those sensations of pain. So a small touch could be felt as a much more powerful sensation causing pain.
Patients may suffer from sensitivities to light, sound, smell, foods, and medications. Cognitive abnormalities are common, similar to “brain fog” from chemotherapy or fibromyalgia. Patients frequently state they have multiple food and drug allergies and intolerances. They commonly become vegan, gluten free and lactose avoiders. This should tip off the physician they are dealing with CSS.
Many patients with this syndrome have inflammation as a common theme with superimposed psychologic disorders. Which one comes first is not always clear. These also could be called psychosomatic disorders—the mind/body connection discussed in my series on chronic pain management found in the subject index on the website home page.
Central sensitivity syndrome has 4 common characteristics:
1) Fibromyalgia 2) irritable bowel syndrome 3) chronic fatigue syndrome 4) Psychological disorders
There are, however, many syndromes being proposed to be included in this nervous system hypersensitivity which comes from a dysregulation of neurotransmitters. An overarching diagnosis of a psychologic disorder is very common.
It has been well known that stroke and spinal cord injury can cause this central sensitization.
Here are 13 disorders that have been proposed that fit the category of this syndrome: 1) fibromyalgia 2) chronic pelvic pain syndrome 3) chronic fatigue syndrome (4) headache and migraine 5) tension headache and migraine low back pain without known cause (idiopathic) 6) low back pain without known cause 7) interstitial cystitis 8) irritable bowel syndrome 9) multiple chemical sensitivity 10) myofascial pain syndrome 11) primary dysmenorrhea (menstrual period pain) 11) restless leg syndrome 12) temporomandibular syndrome (TMJ) 13) Whiplash injuries. Autoimmune disorders can include chronic fatigue and fibromyalgia, therefore, any of these disorders may also be included in this syndrome of multifaceted signs and symptoms.
Here are some of the psychologic disorders commonly diagnosed in these patients: 1) major depression 2) obsessive compulsive disorder (OCD) 3) bipolar disorder 4) PTSD-post-traumatic stress syndrome 5) generalized anxiety disorder 6) panic attacks.
How pain is perceived-normally and in CSS patients
Nociceptors are sensory nerves that normally send pain signals to our body. These same nociceptors send abnormal signals from damaging or potentially damaging stimuli to the spinal cord and brain using chemical neurotransmitters. The most common neurotransmitters are serotonin, dopamine, norepinephrine, GABA-gamma-amino-butyric acid, and glutamate. Whether normal or abnormal, this is the way a person perceives pain.
It is stated that there is an actual abnormality in the dorsal horn ganglion of the spinal cord and the brain. Below is a cross-section of the spinal cord demonstrating the dorsal horn which runs the length of the spinal cord and connects to specific areas in the brain. Note also it connects with the dorsal root to the spinal nerve, which sends pain signals to the area in trouble.
In CSS patients, they feel sensations or experience sensations in an exaggerated way on a neurophysiologic basis. This is not imagined by these patients. This is real for them! Regardless of what or how the disorder begins or the cause, CSS is usually permanent.
Diagnosis and Treatment
There is still some skepticism about this syndrome, but the evidence and acceptability is mounting. It is important to consult with a physician who accepts CSS as a legitimate disorder. Creating a trusting doctor-patient relationship is critical for a patient to open up to their issues and feel comfortable that the physician will work them up and try to find any underlying diseases or disorders that are treatable. Patients must be believed!!
Once the patient’s testing is complete, a plan of action is necessary. This usually includes dealing with psychological issues prescribing behavioral therapy, anti-anxiety and or antidepressants. Seizure medication such as gabapentin (Neurontin) and pregabalin (Lyrica) are often prescribed. These are used frequently for certain types of neuropathy and chronic pain syndromes. Abuse of medications including opioids shoud be discussed. There are side effects that must be understood. Trial and error with any of these medications may be necessary, and patience in getting the right help is necessary.
Treatment of central sensitivity
There is no universal treatment for this syndrome. Like many medical and psychological illnesses, the symptoms must be addressed with both medical and psychological therapy. Treatment of anxiety, depression, neuropathy- like symptoms (benzodiazepines, anti-depressants, and anti-convulsants*) are the medical mainstay for this syndrome. Behavioral therapy is critical to address the overriding psychological results of this pain and suffering. If there is an known cause, that disease must also be treated. These methods have been used to treat most causes of chronic pain today including all the options for pain management.
Explanation of medications
Benzodiazepines include Librium, Valium, Xanax, Ativan, Klonopin, and Restoril, etc.
Anti-depressants include the SSRIs(serotonin selective reuptake inhibitors)-- Effexor, Cymbalta, Pristiq, etc.) and the Tricyclics (second line medications)—Tofranil, Pamelor, Norpramin, etc. Atypical antidepressants—don’t fit into a specific category—Wellbutrin, Remeron, Viibryd, etc. These medications not only help the stress but also, because of the change in neuroreceptor chemicals in the brain that occurs with them, it influences the perception of pain.
Anti-convulsants—These medications change the level of nerve excitability slowing nerve signals down. There is long list of medications that address neuropathy-type symptoms such as the gabapentins (Neurontin), and pregabalin (Lyrica).
Experiments are ongoing using various chemicals that can inhibit central sensitization including ketamine, capsaicin, dextromethorphan, gabapentins, pregabalins, duloxetine, and Cox-2 inhibitors.
It is a real syndrome caused by many factors but the end result is the same….an amplification of neural signaling within the CNS that elicits pain hypersensitivity.
I have addressed chronic pain with an entire series in these recent reports (see Subject Index on the website Homepage for specific reports). We are dealing with a sizable percentage of the population that suffers from chronic pain, and central sensitivity syndrome is just one of several serious causes.
Institute of Chronic Pain; National Institutes of Health (Clifford Wolff-Dept. of Neurobiology)
I recently published an extensive series on chronic pain management that may be helpful. Just click on my website and go to the subject index for the 7 part series.
search for central sensitization
WebMD, National Institutes of Health
New recommendations for the HPV vaccine (Gardasil)
Before discussing cancers of the uterus and cervix, it is important to look at the anatomy of the female pelvic organs.Female pelvic organs-vagina, uterus, ovaries, and fallopian tubes
The uterus is part of the pelvic organs that share space with the ovaries, bladder, and colo-rectum. The uterus has 4 parts—fundus, uterine tubes (fallopian tubes), body, and cervix as seen in the above drawing.
The layers of the uterus consist of the endometrium, the inner layer that sloughs off with a menstrual period, as shown in the drawing below. The middle layer, myometrium, is the muscle layer of the uterus, which contracts and causes menstrual cramps. The outer layer, perimetrium, is continuous with the lining of the abdomen (peritoneum) and its organs. Cancer can occur in the cervix (most common), the fundus, and the body, where endometrial cancer occurs.
It was estimated that 61,380 cases of uterine cancer occurred in 2017 with a little over 10,000 deaths in the U.S. per year.
Cancer of the uterus is rising 1.1% per year, and the primary reason is obesity especially in blacks and whites.
Risk Factors to develop uterine cancer
Risk factors for developing uterine cancer include being menopausal (especially if onset of menopause is late), overweight, diabetic, a high fat diet, have Lynch Syndrome*, and being prescribed Tamoxifen after breast cancer treatment to prevent recurrence and second cancers.
Diagnosis of uterine cancer
Uterine cancer is diagnosed performing a pelvic exam, transvaginal ultrasound, and hysteroscopy with biopsy as shown in the above drawings. If the diagnosis is still in question, a D&C (dilation and curettage) may be necessary (seen below) to scrape the lining out for a biopsy. A Pap smear may detect uterine and even ovarian cancer cells, but are not reliable as a sole procedure.
Unusual vaginal bleeding or discharge, fullness, and pelvic pain all should alert a woman to have a doctor evaluate her pelvis.
Types of uterine cancer
67% of uterine cancers are adenocarcinoma . There are sarcomas of the uterus (5%) as well, and rarely carcinosarcoma, which show mutations in the cancer cells and are more aggressive. Most women will have vaginal bleeding from uterine cancer as the first symptom. A postmenopausal woman with spotting has a 1 in 11 chance of having uterine cancer. JAMA
At the time of diagnosis, 21% of patients have regional disease (outside of the uterus but in the pelvis), and 8% have distant metastases.
Genetic mutations in uterine cancer (Lynch Syndrome)
Sporadic genetic mutations occur, however, 5% do have hereditary genetic mutations including the Lynch Syndrome. Lynch syndrome is a rare hereditary family disease that has a 60% chance of developing uterine cancer and colon cancer without polyps usually diagnosed at an earlier age.
It is an autosomal dominant genetic condition which also has increased risks of ovarian, small intestine, liver and bile duct, kidney, brain, and skin cancer. There is a specific gene mutation (MLH1) gene test that can be ordered ($1000). Close monitoring and yearly endometrial biopsies are indicated or perhaps a hysterectomy after child bearing has passed. Certainly, the other potential cancers must be watched for carefully, especially colon cancer.
It is caused by a DNA repair protein mismatch defect. Cancers can be tested for Lynch Syndrome using a special immunohistochemical stain, which will show a missing repair protein in the DNA. This is critical information for family members as these members have not only a high risk of the first, but also of a second cancer and screening with genetic counseling is highly recommended.
Diagnosis is made with an endometrial biopsy or D&C.
Radical hysterectomy--Surgical removal of uterus, ovaries, and fallopian tubes are the treatment of choice. Examination of the lymph nodes in the pelvis may be biopsied for samples and examination of the peritoneal surface should be examined, whether performed endoscopically or as a laparotomy (open).
If there is disease in the abdomen (outside the uterus), the CA-125 test is valuable as it is in ovarian cancer in following the clinical response.
Radiation and or chemotherapy (Taxol, Cisplatin, Carboplatin, or Adriamycin) may be recommended depending on the stage of disease. 25% of those with the Lynch Syndrome require radiation or chemotherapy as an adjuvant therapy.
The 5 year survival rate is 82% (95% if local, 69% if regional spread, and 16% if distant spread is present). Even patients with Lynch Syndrome induced cancers have the same survival data depending on the stage of disease at diagnosis.
Moffitt Cancer Center, American Cancer Society, Cancer
Cancer of the uterine cervix
Facts about HPV and cervical cancer
There are about 13,240 cases of invasive cervical cancers that occur each year in the U.S. and 4,070 women die, according to the American Cancer Society. It is the fourth most common cancer in women. Thanks to Pap smears (developed in the 1940s), many more non-invasive (carcinoma insitu) lesions can be easily treated.
It is known that the HPV virus (human papilloma virus) is the main cause of most cervical cancers (70%).
If a woman is positive for HPV-DNA in cervical mucus during screening, it means that there is a chance that there is the beginning of the transition to cancer, and must be correlated with the visual examination of the cervix. It can be performed at the same time as a Pap test and may eventually replace the Pap test in the future.
Throat Cancer caused by HPV too!!
What is not well known is that most throat cancers are caused by the HPV virus from oral sexual contact especially in men. Although there is an oral test for HPV from the saliva, it is not an approved test due to inconsistent results. I will discuss this further in a later report. For now, it is necessary to know that HPV can be transmitted from the genital to the oral region (and vice-versa), and safe sex does not prevent it since there is no reasonable way to prevent contact with oral sex (other than abstaining). Oral to oral transmission is also the most likely means. No one is really safe, and really good reason to get the vaccine against this virus.
HPV and Pap testing for women
The federal advisory group (USPSTF) already recommends HPV cervical testing at age 30-65 every 5 years (or Pap smear every 3 years), and Pap smear from age 23-29 every 3 years. The FDA has already approved it be performed without the standard Pap test. No testing is recommended if a woman has had a hysterectomy that included removing the cervix (which almost all are).
The Pap test is a cytology test examining the anatomy of the cervical cells under a microscope and can determine whether these cells are normal, premalignant, or malignant, but HPV may be even more reliable. If both tests are positive, a biopsy will be necessary.
Below is an electron microscopic view of the human papilloma virus (HPV). This is a DNA test of the cervical mucus.
Below is what cervical cells look like with the Pap smear showing HPV infection with progression to cancer. Below are views of the cervix transitioning from a normal cervix on the left progressing
Below is a chart that shows the potential progression from infection to cancer by age. Peak is at 30 years of age.
Incidence of cervical cancer
Cancer of the cervix occurs in younger women (most common 35-44 years of age), however, 15% occur after the age of 65. Even though the federal advisory committee recommends stopping after 65, it should still be considered in women with any higher risks, and as always, needs to be discussed with their doctor. Hispanic women have a higher rate.
The precancerous condition is called CIN3 (carcinoma in-situ 3). Most women who develop HPV infection will clear naturally, but for those that persist, about 30% who develop CIN3 will progress to invasive cancer, which starts rising at age 40. Vaginal HPV infections cause very few symptoms, and therefore are rarely diagnosed and treated.
75% of women who develop cervical cancer will have acquired HPV infection before the age of 30. Most of the precancerous lesions develop between the ages of 25-35.
HPV is more predictive of cervical cancer developing in the future than the Pap smear (cervical cytology).
Cervical Cancer Screening (Pap and HPV)— Current Guidelines from ACS
American Cancer Society screening guidelines (currently a revision is under way)—not for those who have had cervical cancer:
1) The first Pap smear should be performed when the girl becomes sexually active or age 21. This should be performed every 3 years from the first Pap to age 30.
2) HPV testing is not recommended until age 30. Co-testing with the Pap smear and HPV test should be performed until the age of 65 every 5 years or every 3 years with the Pap smear alone.
3) After the age of 65, if there has been normal results with testing for 10 years, it is not recommended to be tested unless symptoms occur or high risk factors exist.
4) If a woman has has had a complete hysterectomy (includes the cervix), no testing is recommended.
5) Even women who have had the HPV vaccine should still follow these guidelines for screening.
Home self testing kits for HPV valuable
A new self testing kit using a vaginal swab was made available for women who were infrequently tested in North Carolina showed comparable positive results to physician collected samples. A test called My Body, My Test was given to 675 women as reported by the Journal Obstetrics and Gynecology, who noted some Scandanavian countries use them for national screening. This is still investigational, but probably would save millions of dollars and reach many women who might not submit to a pelvic exam. It also found comparable results testing for STDs (Chlamydia, gonorrhea, trichomonas and mycoplasma). This could increase screening rates for cervical cancer and some STDs.
HPV vaccine--new age recommendations for vaccine—now ages 11-45
It is estimated by the CDC that over 14 million Americans become infected with the HPV virus annually (and don’t even know it). HPV genital cancers (and genital warts) can be prevented in as many as 88% with the relatively new HPV vaccine (Gardasil 9) recommended for girls and boys from age 11-18 (but can be given 9-26), but the FDA just approved it to be used in men and women ages 27-45 because of its effectiveness in preventing genital diseases (genital warts) including HPV caused cancers (cervical, vaginal, vulvar, and anal cancers).
These are sexually transmitted cancers through this HPV virus. It is critical that all youth and now adults up to 45 get vaccinations (initial and a booster in 6 months). Smoking is another risk factor, as is multiple sex partners, immunosuppressed patients, and those with chronic health diseases. The LBGT community are especially at risk.
The American Cancer Society is currently evaluating current research on revising the cervical cancer screening guidelines that will include not only the Pap smear cytology but the HPV test. JAMA, July, 2018
Signs and symptoms
Bleeding and/or vaginal discharge are the primary symptoms, especially after sex, bleeding after menopause, and bleeding in between periods.
Treatment of pre-cancer (CIN3)
Recurrence of precancerous lesions is common within 5 years, even if treated. Annual exams will be necessary in these cases.
There are different options for treating precancerous lesions of the cervix.
1) Cryosurgery is used to freeze the surface of the cervix and can allow the lining of the cervix to heal back to normal.
2) Laser surgery can also be used to accomplish the same goal. It can also be used to remove some tissue for pathological analysis.
3) Conization is used to remove a deeper level of tissue from the cervix for more advanced precancerous lesions. If abnormal tissue is still present, a more aggressive surgical procedure is necessary (hysterectomy).
Treatment of cervical cancer
Staging of cancer
The extent of the cancer will determine the type of treatment. Stages I-IV are determined with MRI scans, endoscopic evalution if beyond the cervix into the pelvic organs.
There are recent studies that show that more conservative surgical procedures for early stage cervical cancer do not have as good survival data. The standard of care is an open technique using a radical hysterectomy and removal of the regional lymph nodes of the pelvis.
Using minimally invasive techniques including endoscopic uterus removal even with robotic techniques does not control disease as well (86% versus 96.6%) and there are more recurrences. Adding 10.6% survival rates is worth the more aggressive approach, but that is a decision a patient and surgeon must make. There will be a lot of discussion about this over the next year. NEJM, October, 2018
Hysterectomy techniques based on stage of disease:
a) Simple hysterectomy implies removing only the uterus without any surrounding structures. It can be performed through the vagina or with an advanced laparoscopic and or robotic technique. These techniques can also be used for aggressive removal of tissue surrounding the uterus.
b) Radical hysterectomy with radical lymphadenectomy includes removing the uterus and surrounding tissues the uterus with a cuff of vaginal lining plus the pelvic lymph nodes. The ovaries and fallopian tubes are only removed if the cancer has involved these organs. This is performed either through an abdominal incision or laparoscopically with or without robotic techniques. The choice of these techniques is now going to change with brand new scientific data proving a 10% better survival rate with the open technique. Lymph nodes will be removed to analyze them for spread. Radiation or chemotherapy may be added as an adjuvant therapy.
c) Trachelectomy can be performed if there is a desire to have children in the future. It involves removing part of the vagina along with the cervix preserving the rest of the uterus, however, lymph nodes can be removed additionally through the laparoscopic approach. However, miscarriage is higher. This would have to be seriously discussed based on the stage of disease.
d) Pelvic exenteration is a radical removal of part or all of the pelvic organs (bladder, rectum, part of the colon, and vagina including the pelvic lymph nodes. This is usually reserved for recurrent cancers and extensive late stage disease.
5 year survival rates for cervical cancer
Although most cervical cancers are diagnosed at an earlier stage disease with a 80-93% survival rates, however, late stage disease can lead to less than a 20% 5 year survival rate.
Second HPV cancers
HPV cancers that include genital, cervical, anal, and oro-pharyngeal cancers not only occur, but increase the likelihood of a second HPV cancer in the future of these survivors as reported in JAMA Network (81 excess cancers in women and 62 in men per 10,000 people). It was pointed out that careful long term surveillance of these survivors is critical looking for these second cancers that can occur at a different site. It would be advisable to have ENT exam every few years especially in those who have increased risk from tobacco and alcohol excess.
Reference--The American Cancer Society
I have previously discussed other subjects concerning common problems cancer survivors suffer from early and late. I spent 5 years assisting in the development of guidelines for management of cancer survivorship issues (primarily for primary care physicians) with the American Cancer Society and the George Washington Cancer Institute funded by a CDC grant. These are quality of life management issues, and now are finally being addressed in the medical literature and implemented in the healthcare system.
ASCO (American Society of Clinical Oncology) has also formally created guidelines for the management of chronic pain, which affects as many as 40% of survivors. Remember, cancer patients are called “survivors” from the time of diagnosis until the end of life by numerous medical and cancer organizations.
There is no one who is cured of cancer that is not thankful for being free of cancer, but there is a significant price to pay—physically, emotionally, and financially. I am still paying 26 years later with physical side effects from radiation therapy. These potential side effects from treatment must be watched for and can be addressed.
In the face of the opioid abuse crisis (currently discussed in my chronic pain series on the website), it is the physician’s responsibility to inquire about pain, the level, and what medications the patient have been taking to relieve it. Addiction can be a serious issue for cancer survivors.
Many survivors have long standing pain that have never been properly addressed. Referral to pain specialists can discover and treat many of the causes. In fact, these guidelines would be the same for any patient with chronic pain. Cancer survivors deserve a surveillance and treatment plan from the time they finish therapy for the rest of their lives.
Causes of pain in cancer patients-short and long term
Some of the common causes of pain include chemotherapy induced neuropathy, spinal nerve compression, pain in tissues scarred by treatment, headache, etc. Many times the pain may actually have other underlying or contributing causes.
Summary of the salient points made by *ASCO for cancer survivors (applicable to anyone with chronic pain): *ASCO=American Society of Clinical Oncology
1. Pain assessment--all survivors must be screened for pain including a description, location, extent, intensity, and factors which aggravate or relieve the symptoms of pain.
2. Associated symptoms including distress, psychological impact, social, and spiritual factors must discovered. It is critical to assess the impact on daily life.
3. Specific treatments known to cause pain syndromes--it is critical for oncologists and patients to have knowledge of certain types of chemotherapy, immunotherapy, radiation, and surgery that cause certain pain syndromes from direct or indirect pressure or damage to nerves.
4. Multiple treatments--A significant percentage of cancer survivors may require surgery, radiation, and chemotherapy thus doubing and tripling the likelihood of side effects.
Chemo can cause avascular necrosis (loss of blood supply to bone) of bone, neuropathy, and Raynaud’s syndrome. A recent report stated that about half the women who undergo chemo will develop peripheral neuropathy (implies pain in the extremities). This leads to a decline in health, balance problems, and the risk of falls. Sustaining a fracture in a weakened condition with reduced white cells to fight infection will prolong healing. There was a 24% increase in neuropathy in younger women from chemo than older ladies in a recent study. The cause is unknown.
Added risks factors for neuropathy include obesity, less active survivors, and those with co-existing illnesses (cardiovascular, diabetes, etc.). Medpage Today, June, 2017
Common chemotherapeutic agents that cause nerve damage are the platinum agents—cisplatin, carboplatin, oxaliplatin and the vinca alkaloids-vincristine, the taxanes- Paclitaxel, epothilones-ixabepitones, etoposide, tenoposide, thalidomide, and interferon, bortezomib, and lenoalidomide are others. Add immunotherapy (immune checkpoint inhibitors—Keytruda, Optivo, Yervoy; monoclonal antibodies—Campath, Herceptin; Car-T cell therapy) to the list that can cause neuropathy.
The platin chemo agents injure the cell bodies of the dorsal root ganglia (drawing) which is the sensory portion of each nerve that passes out of the spinal cord. Other chemo agents injure in different sites of the nerves
The neuropathy usually begins in the hands and or the feet and creeps up the extremities with tingling and numbness, or shooting and or burning pain with extra sensitivity to temperatures. Although 30-40% of all cancer patients may experience neuropathy, the above chemo agents can cause short or long term symptoms in up to 70% of patients, many of whom may experience it permanently.
These symptoms are the most common reason patients stop their chemo. Childhood cancer requires the use of the platins and vinca alklaloids. Half of these patients will have long lasting neuropathy.
The symptoms can come on during or after treatment and can last for years.
Diagnosing neuropathy with Nerve testing (EMG-electomyogram)
The major nerves in the arms and legs can be tested using a standard nerve conduction study to measure the speed it takes for an electrical stimulus to pass down a nerve to muscles. These speeds are greatly reduced in patients with neuropathy.
Treatment of neuropathy
It includes decreasing the dose, substituting chemo agents, physical therapy, lidoderm patches, meditation, imagery, massage, yoga, acupuncture with electrical stimulation, corticosteroids, anti-depressants, anti-epileptics (gabapentin-Neurontin, Lyrica), and opioids.
Research studies using intravenous calcium and magnesium are being tried and showing about 50% positive results.
Radiation treatments can cause nerve entrapment from scar tissue, reduced range of motion of joints, TMJ syndrome from jaw joint radiation (all of these I suffer from), pelvic radiation can cause cystitis (bladder), proctitis (inflammation of the rectum), enteritis (small bowel), radiculopathy (sciatica, etc.), even secondary malignancies (sarcomas), arthralgia, myalgia, oral and throat pain, etc.
Fortunately, since I received radiation for a throat cancer in 1991, the techniques are somewhat better at protecting normal tissue. The enhanced MRI (below) shows the red area where proton therapy focuses on the throat cancer with much less scatter (note the difference in colors representing lesser amounts of radiation)
IMRT (image modulated radiation therapy using photons) are the most commonly used technique, although, proton therapy is slightly better but much more expensive. Proton therapy still does not reduce the side effects (especially early) much better. Time will tell about late effects. Proton and photon therapy have similar cure rates.
Surgery must remove the cancer but also a zone of normal tissue to be sure all the cancer is removed. Reconstruction using tissue from the surrounding area or distant sites may be necessary. The type of cancer surgery, I performed in my practice required flaps of muscle and skin from the chest wall to reconstruct oral, throat, and neck defects.
These surgeries can cause long term pain by trapping the nerves in scar tissue or directly injuring nerves in the area of resection. Pain, numbness, and disability can occur at the donor and or recipient site. Loss of nerve function to the neck muscles, for instance, can create serious long term neck pain from reduced support of the head (drop head syndrome).
Proper evaluation of these patients
Management of any patient with pain may include referral to physical and or occupational therapy, acupuncture, chiropractic, massage therapy, exercise physiology, a physical medicine specialist, pain management specialists, or a psych evaluation. This approach is called integrative medicine.
Treatment with non-opioid pain medicine
Attempts to treat with non-opioid medications (NSAIDs-Aleve, Ibuprofen, Tylenol, etc.) and muscle relaxants (Flexeril, Soma Compound, etc.) should be tried. Voltaren patches are effective for some milder localized pain. Reducing the dosage of opioids with these additional meds should be attempted. Anti-depressants (off-label) may help pain such as Cymbalta, as well as anti-seizure meds used to treat neuropathy such as Neurontin or Lyrica. Short term use of benzodiazepines (tranquilizers-Xanax, Valium, etc.) may also be helpful.
Cannabinoids from marijuana may be prescribed to relieve pain and or the perception of pain. 23 states and the District of Columbia allow medical use. Many states are even legalizing recreational marijuana.
Cannabidiol (CBD oil) has little euphoric side effects and can be found online or in selected pharmacies. This is in contrast to THC oil which has the euphoric component. It can be smoked, vaped, or taken sublingual.
Although there are many claims about its value, research needs to prove how it works and where it is helpful. For now, it must be used with a certain leap of faith, and many cancer survivors have found its value in improving sleep and helping chronic pain.
a) Screening to identify high risk patients for abuse requires an extensive evaluation of the patient’d family and personal history of previous abuse, underlying psychological issues, a family history of addiction, etc. should be initiated before prescribing opioids. Starting with the mildest form is appropriate. Tramadol is a good start. Short acting opioids (hydrocodone plus acetaminophen) should be used before the longer acting meds such as oxycodone are prescribed, the most abused. The use of morphine, oxymorphine, hydromorphine, and fentanyl all are effective but highly addictive and the dosage and frequency of use of use must be carefully monitored.
b) Patient Education about abuse and addiction should be part of any prescription for narcotics. 80% of the world’s opioids are consumed in the U.S.
c) Dermal (skin) patches using these opiates (fentanyl) have proven to be more effective since they are time-release meds providing a slow release over 24 hours. Less addictive forms of narcotic such as buprenorphine or methadone should be used if abuse begins.
I reported on alternative treatments beginning with the April, 2018 report:
d) Side effects of daily opioids include dizziness, constipation, difficulty urinating, itching, sedation, headache, and must be managed with medications.
e) Serious precautions
The patient must understand the terms tolerance, dependence, abuse, and addiction. Tolerance implies the need for increasing strengths of meds over time. It is advisable to take pain meds when the pain begins rather than waiting until the pain is unbearable.
d) Withdrawal from narcotics must be understood, and when it is time to stop these meds, patients must be instructed to taper off these opioids and never stop abruptly. If a patient has stopped opioids for a few days or weeks, and then needs them again, they should start with the least potent opioids. Taking the dose they previously used, could cause an overdose and death. Patients need to know that an antagonist drug, Narcan, can reverse the effects of opioids and save a life and be on hand in cases of accidental overdose. Talk to your doctor about this.
National Cancer Institute, American Cancer Society, JAMA, Medpage
The Side Effects of pain
Depression, anxiety, sleeplessness, mood disturbance, tension headaches, fatigue, and withdrawal symptoms are all serious side effects of pain and opioids. Patients often do not complain about these issues but must!!
The financial pain of cancer
Financial distress occurs with every cancer patient and their families. This is very serious and adds greatly to the emotional burden on the family and survivor. It can create guilt for the survivor knowing it is causing serious financial stress for loved ones.
The cost of cancer treatments are more expensive than any other disease costing $895 billion annually in the U.S. according to the American Institute of Cancer Research. (heart disease costs $753 billion).
3% of cancer patients go bankrupt as a result of cancer care. Research has proven that the death rate for those who become financially destroyed is higher than other cancer survivors.
50% of the cost is derived from outpatient facilities and doctor’s offices (that would include radiation and chemotherapy), 35% from inpatient hospital services, and 11% from medications.
The price for staying alive just one extra year is calculated to be $207,000.
The average cost of major cancer surgery is between $30-50,000. The average cost of radiation is $25-35,000. Proton therapy may be triple in cost.
Many of the newer cancer medical therapies cost $10-13,000 for a single chemo drug per month. Many patients will need a combination of drugs costing over $250,000 for a year especially if the new immunologic treatments are added. Many must continue that treatment indefinitely. These fees do not include physician’s fees, outpatient facility fees, laboratory, and costs for treating the side effects of treatment.
Most insurance will pay only 70-80% of the cost, and therefore the co-pay can reach $thousands per month for all costs including housing, transportation, loss of wages, loss of some employment, premiums for insurance, prescriptions for pain, antibiotics, etc. according to ASCO (American Society of Clinical Oncology).
According to the American Cancer Society, one quarter of Americans put off tests for cancer screening, etc. because of the cost. It is much better to catch a cancer early since the cure rates are much higher.
1 out 5 Americans over 65 have used up their savings because of healthcare costs.
The average cost per patient in 2011 for a cancer diagnosis and treatment was $86,000 according to the Healthcare Research Agency. Can you imagine what it is today? I would double that cost today.
U.S. News and World Report, ASCO, ACS, cancerinsurance.com
That completes the January, 2019 report. The February, 2019 report’s subjects will be:
1) Migraines and new medications to prevent them
2) Medical Updates—Medicare spending; Statins for the elderly; Millenials prefer “fast food type” of medicine; Coke, beer, and other products may add marijuana products; Sugar in yogurt; update on Medicare spending
3) New Treatment for alcoholism; alcoholic hepatitis
4) Update on MS-Multiple Sclerosis
5) Golf injuries, and stretches to prevent them
6) Uterine diseases-part 2--Fibroids, endometriosis, etc.
Stay healthy and well, my friends, and Happy New Year!! Dr. Sam