The sound solution for breast cancer

We have long known that breasts change with age. It is a perfectly natural process but one that women have been fighting for generations. Gravity always wins in the end, particularly over women with large boobs who have had several pregnancies. Joggers can suffer particularly badly. But whilst this age related sagging might not be desirable from an aesthetic point of view, it does have a very useful property from a medical one. The older you get, the less dense your boobs get and the easier it is to image them for lumps. This is the reason why we don’t offer mammograms to young women. Currently on the NHS screening is offered from the age of 47, and this is not just to do with money. It really is more effective after this age. Young boobs just don’t x-ray well. But now the results of new studies show another property of breast density, but this one is not so good. There is increasing evidence that density is a key factor in breast cancer. Women with more tissue than fat in their breasts are up to five times more at risk because they have more cells. Those involved in the research have suggested that all women should be advised of their breast density, and all should be offered ultrasound scans, to pick up tumours that mammography may have missed. The theory is that denser breasts hide their lumps from x-rays, but may reveal them to ultrasound. Of course since this information has been released the usual loud clamouring has started, demanding that the already overstretched NHS offers this extra screening test to all women.
Our current screening program is great. Mammography lowers breast cancer mortality by 15% to 20%. But if ultrasound can further improve this then surely it should be added to the program too? The problem is that it is very operator dependent, and in multiple trials comparing the accuracy of mammography plus ultrasound to that of mammography alone in women with denser breasts who were at high risk for breast cancer, the addition of ultrasound to mammography did result in detection of additional cases of cancer, but at the expense of a roughly fourfold increase in false-positives. This means that four times as many women would have to undergo an invasive biopsy procedure that they do not need if this method of screening was introduced. This would cause a level of anxiety that may be acceptable in a high-risk population, but certainly would not be in lower-risk patients. An unobtainable number of extra man-hours would also be needed to cope with the increased counselling involved.
Neither can ultrasound consistently detect certain early signs of cancer such as tiny deposits of calcium in the breast that cannot be felt but can be seen on a conventional mammogram. Nor does it have good spatial resolution like mammography, and therefore cannot provide as much detail as a mammogram image.
What is not being publicised is the fact that the combination of mammography and ultrasound still missed one out of every five cancers. So ultrasound is certainly not a silver bullet for breast cancer screening and shouldn’t be hailed as such. Perhaps rather than shouting that women are being denied ‘life saving cancer tests’ we should be a little more measured in our approach and look for ways to improve the uptake of mammography itself. Still too many women do not attend. Also, ensuring all screening programs offer digital imaging, which is more accurate still, may be a better use of time and money, and will avoid creating a cohort of worried and confused women.

Breaking the migraine barrier

New research looking into the causes of migraines has produced what may be one of the most important and useful medical findings of the century. Scientists have found a gene that regulates how pain is felt in the brain, a gene that can be turned up or down. Called TRESK, the gene controls the sensitivity of pain nerves in the brain and it is thought that migraine sufferers may have a fault in their gene, causing the extreme sensitivity to light, noise and touch experienced during a migraine.

It’s an exciting discovery as it may lead to the creation of a new generation of drugs that can simply turn up the threshold at which the body feels pain making migraines a thing of the past. It not just migraines that will benefit however, as it could potentially lead to a new form of painkiller being developed as well. As the gene is susceptible to being switched on and off with drugs it means that it could be altered to increase the threshold to such an extent it eliminates the feeling of pain altogether.
Migraines cause a considerable burden to sufferers and their work. In the UK around 18 per cent of women and 8 per cent of men get migraines resulting in the loss of more than 25 million working days a year. The World Health Organisation has named migraine as a leading cause of disability worldwide and it has been estimated to be the most costly neurological disorder in Europe.

Sadly migraines are often very badly managed by the medical profession, many of whom still continue to promote ideas like its cheese, or chocolate that cause migraines. Actually the situation is more complex, and it is necessary for more than one trigger to be present, possible more than 48 hours before the onset of headache, in order to cross the threshold that leads to an attack. Contrary to popular belief migraines are not caused by food allergy either, and no specific antigen-antibody reaction has ever been identified although certain foods may be one of a complex of triggers. Actually, missing meals (resulting in a drop in blood sugar) and dehydration are far more important triggers. Changes in sleep pattern, hormonal changes, head and neck pains and stress are all other culprits. Very little time is spent explaining and helping to identify these interacting triggers and existing treatments are often not taken early enough. There is currently no cure for migraines but many different treatments are available which can be effective if used correctly. The problem is that it can require quite a bit of personal experimenting with different types and combinations of medicines before the most effective one is found. Even simple painkillers can work well, but many people only take painkillers when their headache becomes very bad. This is usually too late for any benefit to be felt.


My top 5 tips if your migraines are poorly controlled are:

1) Identify prodromal symptoms like changes in mood or behaviour to help identify as early as possible when a migraine may be imminent.
2) Keep a diary of all the details of what you were doing for the few days before an attack to help you better understand them.
3) Identify your specific triggers and gradually cut them from your life, if possible.
4) Take treatment early –by identifying the warning signs this should usually be possible.
5) Always carry treatment with you and ideally a little food and drink too.

If you feel your migraines are not under control then ask your GP for a referral to a specialist migraine clinic for further advice.

Teen Sexual Health

As a sexual health doctor the recent visit of the Pope made me angry for an obvious number of reasons. In rebellion I want to announce that the 26th September this year is World Contraception Day and we should all mark it. It’s not a day I expect many to have ever heard of, and it is perhaps considered a little too Hallmark for some, but given the statistic that approximately a third of the 205 million pregnancies that occur each year worldwide are unplanned, the need for such a day can be clearly seen. To mark the event a multi-national survey looking at attitudes towards contraception has been undertaken. The results are depressing although pretty unsurprising. They highlight a significant disconnect between what young people know they should be doing for contraception, and what they are actually doing in their day to day lives. It also shows that highly unreliable contraceptive methods, such as the ‘withdrawal method’ are still being viewed as effective by almost a third of young people. Perhaps most depressing of all is the news that that the highest reported rates of STIs are found among young people aged between 15 and 24. Nearly half report that they prioritize personal hygiene, including showering, waxing and applying perfume, above contraception, and teens in the UK reported that the reason why they failed to use condoms was because they were often too drunk to remember.
Straight from the school of the bleeding obvious, this apparently earth-shattering revelation that the appalling STI and pregnancy rates amongst UK teenagers maybe linked to the significant increase in binge drinking observed over the last few years has grabbed headlines but I find it truly hard to believe that no one has made this observation before. Experts quite rightly describe the findings as alarming, but disagree over whether the solution lies in providing more contraception or better efforts to rein in binge drinking. I think improving sex education would be a better starting place, by including more focus on relationships, feelings, emotions, confidence and respect. The British media could also do a lot to help, by stopping its prudish campaign of being deliberately and mischievously resolved to undermine any sexual health/education initiative aimed at helping young people and their parents. I can but dream. I personally find the results alarming because sadly I cannot now see a truly effective solution actually being implemented. The problem is that until the government addresses its ludicrously hypocritical drug and alcohol laws things are only likely to get worse. Making legal (and, let’s be honest, frankly encouraging the use of) the one drug that causes considerable self-destructive behaviour and affects judgement in the way that alcohol does is absurd. It gives such a confused message to our young people that I weep for the future. Yes, alcohol is responsible for many a condomless encounter because that is the one property of alcohol that we most embrace –its ability to make us relax and forget. Teens are no more going to stop drinking than the Catholic Church is going to repeal some of its insane views on sex and contraception.