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TV watching linked to depression
While anxiety was at the top of my list of emotional states that generated office visits in my pediatric practice, depression always ran a close second. Not infrequently, patients would report symptoms that suggested they were harboring both morbidities.
Although some families appear to be prone to depression, I’m not aware that a definable genetic basis has been discovered. Like me, you may have wondered what factors determine whether an individual will become depressed or merely be unhappy when things aren’t going well. We all have known people who have weathered disappointment and life-altering calamities without even a hint of being depressed. On the other hand you probably have met numerous patients and acquaintances who have become significantly depressed as the result of simply worrying that some disaster might befall them.
Is this variable vulnerability to depression the result of some as yet undiscovered neurotransmitter? Or are there certain lifestyle features that make individuals more prone to depression? Or ... could it be both? In other words are there behaviors that can tweak a person’s telomeres in such a way that triggers a biochemical cascade that results in depression?
A recent paper in the American Journal of Psychiatry doesn’t drill down through the genetic and biochemical strata, but it does suggest that there are “modifiable” behaviors that may contribute to depression. The researchers based at Harvard Medical School in Boston accessed a database of more than 100,000 adults in the United Kingdom. With use of a two-stage method that included a strategy similar to that employed for identifying genetic risk factors for disease, the researchers scanned a large number of factors that they considered modifiable, searching for those that might be associated with the development of depression.
Not surprisingly, they discovered that those respondents who more frequently confided in others and more frequently visited with family and friends were less likely to become depressed. Of course, this protective effect of social connection can cut both ways during the pandemic. During this pandemic if those people you confide in are not currently in your “bubble,” you may have a problem. This may explain why, despite warnings of their dangers, bars continue to be so attractive. It’s probably not just the alcohol but it’s the bartenders and patrons who are willing to listen that patrons seek out. It would be helpful if more people felt comfortable sharing their feelings with members of their family bubble. But you and I know that many families don’t come even close to matching the Brady Bunch image of a functionality.
Somewhat surprisingly to the Harvard researchers was their finding that time watching television also was a significant risk factor for the development of depression. Their data did not allow them to determine whether this observation was linked to the sedentary nature of television watching or the content of the shows being viewed. I suspect that content is not the problem. But in addition to being a sedentary activity, television watching often is isolating. When television was first introduced to the mass market, families grouped around the household’s lone set, much as families did back when radios became popular. In their infancy radio listening and television viewing were social activities rich with discussion and shared emotions.
However, as televisions became less expensive and no longer required large pieces of furniture to house them, television viewing became a more solitary and individual activity. Televisions became obligatory furnishings of every bedroom, and parents and children could withdraw to their own spaces and be entertained free of any opportunity or obligation to interact with the rest of family.
This new research into the risk factors for depression suggests that again without any way of monitoring their usage. At least among children, television watching should be a modifiable behavior.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
While anxiety was at the top of my list of emotional states that generated office visits in my pediatric practice, depression always ran a close second. Not infrequently, patients would report symptoms that suggested they were harboring both morbidities.
Although some families appear to be prone to depression, I’m not aware that a definable genetic basis has been discovered. Like me, you may have wondered what factors determine whether an individual will become depressed or merely be unhappy when things aren’t going well. We all have known people who have weathered disappointment and life-altering calamities without even a hint of being depressed. On the other hand you probably have met numerous patients and acquaintances who have become significantly depressed as the result of simply worrying that some disaster might befall them.
Is this variable vulnerability to depression the result of some as yet undiscovered neurotransmitter? Or are there certain lifestyle features that make individuals more prone to depression? Or ... could it be both? In other words are there behaviors that can tweak a person’s telomeres in such a way that triggers a biochemical cascade that results in depression?
A recent paper in the American Journal of Psychiatry doesn’t drill down through the genetic and biochemical strata, but it does suggest that there are “modifiable” behaviors that may contribute to depression. The researchers based at Harvard Medical School in Boston accessed a database of more than 100,000 adults in the United Kingdom. With use of a two-stage method that included a strategy similar to that employed for identifying genetic risk factors for disease, the researchers scanned a large number of factors that they considered modifiable, searching for those that might be associated with the development of depression.
Not surprisingly, they discovered that those respondents who more frequently confided in others and more frequently visited with family and friends were less likely to become depressed. Of course, this protective effect of social connection can cut both ways during the pandemic. During this pandemic if those people you confide in are not currently in your “bubble,” you may have a problem. This may explain why, despite warnings of their dangers, bars continue to be so attractive. It’s probably not just the alcohol but it’s the bartenders and patrons who are willing to listen that patrons seek out. It would be helpful if more people felt comfortable sharing their feelings with members of their family bubble. But you and I know that many families don’t come even close to matching the Brady Bunch image of a functionality.
Somewhat surprisingly to the Harvard researchers was their finding that time watching television also was a significant risk factor for the development of depression. Their data did not allow them to determine whether this observation was linked to the sedentary nature of television watching or the content of the shows being viewed. I suspect that content is not the problem. But in addition to being a sedentary activity, television watching often is isolating. When television was first introduced to the mass market, families grouped around the household’s lone set, much as families did back when radios became popular. In their infancy radio listening and television viewing were social activities rich with discussion and shared emotions.
However, as televisions became less expensive and no longer required large pieces of furniture to house them, television viewing became a more solitary and individual activity. Televisions became obligatory furnishings of every bedroom, and parents and children could withdraw to their own spaces and be entertained free of any opportunity or obligation to interact with the rest of family.
This new research into the risk factors for depression suggests that again without any way of monitoring their usage. At least among children, television watching should be a modifiable behavior.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
While anxiety was at the top of my list of emotional states that generated office visits in my pediatric practice, depression always ran a close second. Not infrequently, patients would report symptoms that suggested they were harboring both morbidities.
Although some families appear to be prone to depression, I’m not aware that a definable genetic basis has been discovered. Like me, you may have wondered what factors determine whether an individual will become depressed or merely be unhappy when things aren’t going well. We all have known people who have weathered disappointment and life-altering calamities without even a hint of being depressed. On the other hand you probably have met numerous patients and acquaintances who have become significantly depressed as the result of simply worrying that some disaster might befall them.
Is this variable vulnerability to depression the result of some as yet undiscovered neurotransmitter? Or are there certain lifestyle features that make individuals more prone to depression? Or ... could it be both? In other words are there behaviors that can tweak a person’s telomeres in such a way that triggers a biochemical cascade that results in depression?
A recent paper in the American Journal of Psychiatry doesn’t drill down through the genetic and biochemical strata, but it does suggest that there are “modifiable” behaviors that may contribute to depression. The researchers based at Harvard Medical School in Boston accessed a database of more than 100,000 adults in the United Kingdom. With use of a two-stage method that included a strategy similar to that employed for identifying genetic risk factors for disease, the researchers scanned a large number of factors that they considered modifiable, searching for those that might be associated with the development of depression.
Not surprisingly, they discovered that those respondents who more frequently confided in others and more frequently visited with family and friends were less likely to become depressed. Of course, this protective effect of social connection can cut both ways during the pandemic. During this pandemic if those people you confide in are not currently in your “bubble,” you may have a problem. This may explain why, despite warnings of their dangers, bars continue to be so attractive. It’s probably not just the alcohol but it’s the bartenders and patrons who are willing to listen that patrons seek out. It would be helpful if more people felt comfortable sharing their feelings with members of their family bubble. But you and I know that many families don’t come even close to matching the Brady Bunch image of a functionality.
Somewhat surprisingly to the Harvard researchers was their finding that time watching television also was a significant risk factor for the development of depression. Their data did not allow them to determine whether this observation was linked to the sedentary nature of television watching or the content of the shows being viewed. I suspect that content is not the problem. But in addition to being a sedentary activity, television watching often is isolating. When television was first introduced to the mass market, families grouped around the household’s lone set, much as families did back when radios became popular. In their infancy radio listening and television viewing were social activities rich with discussion and shared emotions.
However, as televisions became less expensive and no longer required large pieces of furniture to house them, television viewing became a more solitary and individual activity. Televisions became obligatory furnishings of every bedroom, and parents and children could withdraw to their own spaces and be entertained free of any opportunity or obligation to interact with the rest of family.
This new research into the risk factors for depression suggests that again without any way of monitoring their usage. At least among children, television watching should be a modifiable behavior.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Breast cancer screening complexities
Breast cancer in women remains one of the most common types of cancer in the United States, affecting about one in eight women1 over the course of their lifetime. Despite its pervasiveness, the 5-year survival rate for women with breast cancer remains high, estimated at around 90%2 based on data from 2010-2016, in large part because of early detection and treatment through screening. However, many organizations disagree on when to start and how often to screen women at average risk.
Important to discussions about breast cancer screening is the trend that many women delay childbirth until their 30s and 40s. In 2018 the birth rate increased for women ages 35-44, and the mean age of first birth increased from the prior year across all racial and ethnic groups.3 Therefore, ob.gyns. may need to consider that their patients not only may have increased risk of developing breast cancer based on age alone – women aged 35-44 have four times greater risk of disease than women aged 20-342 – but that the pregnancy itself may further exacerbate risk in older women. A 2019 pooled analysis found that women who were older at first birth had a greater chance of developing breast cancer compared with women with no children.4
In addition, ob.gyns. should consider that their patients may have received a breast cancer diagnosis prior to initiation or completion of their family plans or that their patients are cancer survivors – in 2013-2017, breast cancer was the most common form of cancer in adolescents and young adults.5 Thus, practitioners should be prepared to discuss not only options for fertility preservation but the evidence regarding cancer recurrence after pregnancy.
We have invited Dr. Katherine Tkaczuk, professor of medicine at the University of Maryland School of Medicine* and director of the breast evaluation and treatment program at the Marlene and Stewart Greenebaum Comprehensive Cancer Center, to discuss the vital role of screening in the shared decision-making process of breast cancer prevention.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore,* as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at obnews@mdedge.com.
Correction, 1/8/21: *An earlier version of this article misstated the university affiliations for Dr. Tkaczuk and Dr. Reece.
References
1. U.S. Breast Cancer Statistics. breastcancer.org.
2. “Cancer Stat Facts: Female Breast Cancer,” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
3. Martin JA et al. “Births: Final Data for 2018.” National Vital Statistics Reports. 2019 Nov 27;68(13):1-46.
4. Nichols HB et al. Ann Intern Med. 2019 Jan;170(1):22-30.
5. “Cancer Stat Facts: Cancer Among Adolescents and Young Adults (AYAs) (Ages 15-39),” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
Breast cancer in women remains one of the most common types of cancer in the United States, affecting about one in eight women1 over the course of their lifetime. Despite its pervasiveness, the 5-year survival rate for women with breast cancer remains high, estimated at around 90%2 based on data from 2010-2016, in large part because of early detection and treatment through screening. However, many organizations disagree on when to start and how often to screen women at average risk.
Important to discussions about breast cancer screening is the trend that many women delay childbirth until their 30s and 40s. In 2018 the birth rate increased for women ages 35-44, and the mean age of first birth increased from the prior year across all racial and ethnic groups.3 Therefore, ob.gyns. may need to consider that their patients not only may have increased risk of developing breast cancer based on age alone – women aged 35-44 have four times greater risk of disease than women aged 20-342 – but that the pregnancy itself may further exacerbate risk in older women. A 2019 pooled analysis found that women who were older at first birth had a greater chance of developing breast cancer compared with women with no children.4
In addition, ob.gyns. should consider that their patients may have received a breast cancer diagnosis prior to initiation or completion of their family plans or that their patients are cancer survivors – in 2013-2017, breast cancer was the most common form of cancer in adolescents and young adults.5 Thus, practitioners should be prepared to discuss not only options for fertility preservation but the evidence regarding cancer recurrence after pregnancy.
We have invited Dr. Katherine Tkaczuk, professor of medicine at the University of Maryland School of Medicine* and director of the breast evaluation and treatment program at the Marlene and Stewart Greenebaum Comprehensive Cancer Center, to discuss the vital role of screening in the shared decision-making process of breast cancer prevention.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore,* as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at obnews@mdedge.com.
Correction, 1/8/21: *An earlier version of this article misstated the university affiliations for Dr. Tkaczuk and Dr. Reece.
References
1. U.S. Breast Cancer Statistics. breastcancer.org.
2. “Cancer Stat Facts: Female Breast Cancer,” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
3. Martin JA et al. “Births: Final Data for 2018.” National Vital Statistics Reports. 2019 Nov 27;68(13):1-46.
4. Nichols HB et al. Ann Intern Med. 2019 Jan;170(1):22-30.
5. “Cancer Stat Facts: Cancer Among Adolescents and Young Adults (AYAs) (Ages 15-39),” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
Breast cancer in women remains one of the most common types of cancer in the United States, affecting about one in eight women1 over the course of their lifetime. Despite its pervasiveness, the 5-year survival rate for women with breast cancer remains high, estimated at around 90%2 based on data from 2010-2016, in large part because of early detection and treatment through screening. However, many organizations disagree on when to start and how often to screen women at average risk.
Important to discussions about breast cancer screening is the trend that many women delay childbirth until their 30s and 40s. In 2018 the birth rate increased for women ages 35-44, and the mean age of first birth increased from the prior year across all racial and ethnic groups.3 Therefore, ob.gyns. may need to consider that their patients not only may have increased risk of developing breast cancer based on age alone – women aged 35-44 have four times greater risk of disease than women aged 20-342 – but that the pregnancy itself may further exacerbate risk in older women. A 2019 pooled analysis found that women who were older at first birth had a greater chance of developing breast cancer compared with women with no children.4
In addition, ob.gyns. should consider that their patients may have received a breast cancer diagnosis prior to initiation or completion of their family plans or that their patients are cancer survivors – in 2013-2017, breast cancer was the most common form of cancer in adolescents and young adults.5 Thus, practitioners should be prepared to discuss not only options for fertility preservation but the evidence regarding cancer recurrence after pregnancy.
We have invited Dr. Katherine Tkaczuk, professor of medicine at the University of Maryland School of Medicine* and director of the breast evaluation and treatment program at the Marlene and Stewart Greenebaum Comprehensive Cancer Center, to discuss the vital role of screening in the shared decision-making process of breast cancer prevention.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore,* as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at obnews@mdedge.com.
Correction, 1/8/21: *An earlier version of this article misstated the university affiliations for Dr. Tkaczuk and Dr. Reece.
References
1. U.S. Breast Cancer Statistics. breastcancer.org.
2. “Cancer Stat Facts: Female Breast Cancer,” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
3. Martin JA et al. “Births: Final Data for 2018.” National Vital Statistics Reports. 2019 Nov 27;68(13):1-46.
4. Nichols HB et al. Ann Intern Med. 2019 Jan;170(1):22-30.
5. “Cancer Stat Facts: Cancer Among Adolescents and Young Adults (AYAs) (Ages 15-39),” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
An oncologist’s view on screening mammography
Screening mammography has contributed to the lowering of mortality from breast cancer by facilitating earlier diagnosis and a lower stage at diagnosis. With more effective treatment options for women who are diagnosed with lower-stage breast cancer, the current 5-year survival rate has risen to 90% – significantly higher than the 5-year survival rate of 75% in 1975.1
Women who are at much higher risk for developing breast cancer – mainly because of family history, certain genetic mutations, or a history of radiation therapy to the chest – will benefit the most from earlier and more frequent screening mammography as well as enhanced screening with non-x-ray methods of breast imaging. It is important that ob.gyns. help to identify these women.
However, the majority of women who are screened with mammography are at “average risk,” with a lifetime risk for developing breast cancer of 12.9%, based on 2015-2017 data from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results Program (SEER).1 The median age at diagnosis of breast cancer in the U.S. is 62 years,1 and advancing age is the most important risk factor for these women.
A 20% relative risk reduction in breast cancer mortality with screening mammography has been demonstrated both in systematic reviews of randomized and observational studies2 and in a meta-analysis of 11 randomized trials comparing screening and no screening.3 Even though the majority of randomized trials were done in the age of film mammography, experts believe that we still see at least a 20% reduction today.
Among average-risk women, those aged 50-74 with a life expectancy of at least 10 years will benefit the most from regular screening. According to the 2016 screening guideline of the United States Preventive Services Task Force (USPSTF), relative risk reductions in breast cancer mortality from mammography screening, by age group, are 0.88 (confidence interval, 0.73-1.003) for ages 39-49; 0.86 (CI, 0.68-0.97) for ages 50-59; 0.67 (CI, 0.55-0.91) for ages 60-69; and 0.80 (CI, 0.51 to 1.28) for ages 70-74.2
For women aged 40-49 years, most of the guidelines in the United States recommend individualized screening every 1 or 2 years – screening that is guided by shared decision-making that takes into account each woman’s values regarding relative harms and benefits. This is because their risk of developing breast cancer is relatively low while the risk of false-positive results can be higher.
A few exceptions include guidelines by the National Comprehensive Cancer Network (NCCN) and the American College of Radiology, which recommend annual screening mammography starting at age 40 years for all average-risk women. In our program, we adhere to these latter recommendations and advise annual digital 3-D mammograms starting at age 40 and continuing until age 74, or longer if the woman is otherwise healthy with a life expectancy greater than 10 years.
Screening and overdiagnosis
Overdiagnosis – the diagnosis of cancers that may not actually cause mortality or may not even have become apparent without screening – is a concern for all women undergoing routine screening for breast cancer. There is significant uncertainty about its frequency, however.
Research cited by the USPSTF suggests that as many as one in five women diagnosed with breast cancer over approximately 10 years will be overdiagnosed. Other modeling studies have estimated one in eight overdiagnoses, for women aged 50-75 years specifically. By the more conservative estimate, according to the USPSTF, one breast cancer death will be prevented for every 2-3 cases of unnecessary treatment.2
Ductal carcinoma in situ is confined to the mammary ductal-lobular system and lacks the classic characteristics of cancer. Technically, it should not metastasize. But we do not know with certainty which cases of DCIS will or will not progress to invasive cancer. Therefore these women often are offered surgical approaches mirroring invasive cancer treatments (lumpectomy with radiation or even mastectomy in some cases), while for some, such treatments may be unnecessary.
Screening younger women (40-49)
Shared decision-making is always important for breast cancer screening, but in our program we routinely recommend annual screening in average-risk women starting at age 40 for several reasons. For one, younger women may present with more aggressive types of breast cancer such as triple-negative breast cancer. These are much less common than hormone-receptor positive breast cancers – they represent 15%-20% of all breast cancers – but they are faster growing and may develop in the interim if women are screened less often (at 2-year intervals).
In addition, finding an invasive breast cancer early is almost always beneficial. Earlier diagnosis (lower stage at diagnosis) is associated with increased breast cancer-specific and overall survival, as well as less-aggressive treatment approaches.
As a medical oncologist who treats women with breast cancer, I see these benefits firsthand. With earlier diagnosis, we are more likely to offer less aggressive surgical approaches such as partial mastectomy (lumpectomy) and sentinel lymph node biopsy as opposed to total mastectomy with axillary lymph node dissection, the latter of which is more likely to be associated with lymphedema and which can lead to postmastectomy chest wall pain syndromes.
We also are able to use less aggressive radiation therapy approaches such as partial breast radiation, and less aggressive breast cancer–specific systemic treatments for women with a lower stage of breast cancer at diagnosis. In some cases, adjuvant or neoadjuvant chemotherapy may not be needed – and when it is necessary, shorter courses of chemotherapy or targeted chemotherapeutic regimens may be offered. This means lower systemic toxicities, both early and late, such as less cytopenias, risk of infections, mucositis, hair loss, cardiotoxicity, secondary malignancies/leukemia, and peripheral sensory neuropathy.
It is important to note that Black women in the United States have the highest death rate from breast cancer – 27.3 per 100,000 per year, versus 19.6 per 100,000 per year for White women1 – and that younger Black women appear to have a higher risk of developing triple-negative breast cancer, a more aggressive type of breast cancer. The higher breast cancer mortality in Black women is likely multifactorial and may be attributed partly to disparities in health care and partly to tumor biology. The case for annual screening in this population thus seems especially strong.
Screening modalities
Digital 3-D mammography, or digital breast tomosynthesis (DBT), is widely considered to be a more sensitive screening tool than conventional digital mammography alone. The NCCN recommends DBT for women with an average risk of developing breast cancer starting at age 40,4,5 and the USPSTF, while offering no recommendation on DBT as a primary screening method (“insufficient evidence”), says that DBT appears to increase cancer detection rates.2 So, I do routinely recommend it.
DBT may be especially beneficial for women with dense breast tissue (determined mammographically), who are most often premenopausal women – particularly non-Hispanic White women. Dense breast tissue itself can contribute to an increased risk of breast cancer – an approximately 20% higher relative risk in an average-risk woman with heterogeneously dense breast tissue, and an approximately 100% higher relative risk in a woman with extremely dense breasts6 – but unfortunately it affects the sensitivity and specificity of screening mammography.
I do not recommend routine supplemental screening with other methods (breast ultrasonography or MRI) for women at average risk of breast cancer who have dense breasts. MRI with gadolinium contrast is recommended as an adjunct to mammography for women who have a lifetime risk of developing breast cancer of more than 20%-25% (e.g., women with known BRCA1/2 mutations or radiation to breast tissue), and can be done annually at the same time as the screening mammogram is done. Some clinicians and patients prefer to alternate these two tests – one every 6 months.
Screening breast MRI is more sensitive but less specific than mammography; combining the two screening modalities leads to overall increased sensitivity and specificity in high-risk populations.
Risk assessment
Identifying higher-risk women who need to be sent to a genetic counselor is critically important. The USPSTF recommends that women who have family members with breast, ovarian, tubal or peritoneal cancer, or who have an ancestry associated with BRCA1/2 gene mutations, be assessed with a brief familial risk assessment tool such as the Pedigree Assessment Tool. This and other validated tools have been evaluated by the USPSTF and can be used to guide referrals to genetic counseling for more definitive risk assessment.7
These tools are different from general breast cancer risk assessment models, such as the NCI’s Breast Cancer Risk Assessment Tool,8 which are designed to calculate the 5-year and lifetime risk of developing invasive breast cancer for an average-risk woman but not to identify BRCA-related cancer risk. (The NCI’s tool is based on the Gail model, which has been widely used over the years.)
The general risk assessment models use a women’s personal medical and reproductive history as well as the history of breast cancer among her first-degree relatives to estimate her risk.
Dr. Tkaczuk reported that she has no disclosures.
References
1. “Cancer Stat Facts: Female Breast Cancer.” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
2. Siu AL et al. Ann Intern Med. 2016 Feb 16. doi: 10.7326/M15-2886.
3. Independent UK Panel on Breast Cancer Screening. Lancet. 2012 Nov 17;380(9855):1778-86.
4. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Screening and Diagnosis. National Comprehensive Cancer Network.
5. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Risk Reduction. National Comprehensive Cancer Network.
6. Ziv E et al. Cancer Epidemiol Biomarkers Prev. 2004;13(12):2090-5.
7. USPSTF. JAMA. 2019;322(7):652-65.
8. The Breast Cancer Risk Assessment Tool. National Cancer Institute.
Screening mammography has contributed to the lowering of mortality from breast cancer by facilitating earlier diagnosis and a lower stage at diagnosis. With more effective treatment options for women who are diagnosed with lower-stage breast cancer, the current 5-year survival rate has risen to 90% – significantly higher than the 5-year survival rate of 75% in 1975.1
Women who are at much higher risk for developing breast cancer – mainly because of family history, certain genetic mutations, or a history of radiation therapy to the chest – will benefit the most from earlier and more frequent screening mammography as well as enhanced screening with non-x-ray methods of breast imaging. It is important that ob.gyns. help to identify these women.
However, the majority of women who are screened with mammography are at “average risk,” with a lifetime risk for developing breast cancer of 12.9%, based on 2015-2017 data from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results Program (SEER).1 The median age at diagnosis of breast cancer in the U.S. is 62 years,1 and advancing age is the most important risk factor for these women.
A 20% relative risk reduction in breast cancer mortality with screening mammography has been demonstrated both in systematic reviews of randomized and observational studies2 and in a meta-analysis of 11 randomized trials comparing screening and no screening.3 Even though the majority of randomized trials were done in the age of film mammography, experts believe that we still see at least a 20% reduction today.
Among average-risk women, those aged 50-74 with a life expectancy of at least 10 years will benefit the most from regular screening. According to the 2016 screening guideline of the United States Preventive Services Task Force (USPSTF), relative risk reductions in breast cancer mortality from mammography screening, by age group, are 0.88 (confidence interval, 0.73-1.003) for ages 39-49; 0.86 (CI, 0.68-0.97) for ages 50-59; 0.67 (CI, 0.55-0.91) for ages 60-69; and 0.80 (CI, 0.51 to 1.28) for ages 70-74.2
For women aged 40-49 years, most of the guidelines in the United States recommend individualized screening every 1 or 2 years – screening that is guided by shared decision-making that takes into account each woman’s values regarding relative harms and benefits. This is because their risk of developing breast cancer is relatively low while the risk of false-positive results can be higher.
A few exceptions include guidelines by the National Comprehensive Cancer Network (NCCN) and the American College of Radiology, which recommend annual screening mammography starting at age 40 years for all average-risk women. In our program, we adhere to these latter recommendations and advise annual digital 3-D mammograms starting at age 40 and continuing until age 74, or longer if the woman is otherwise healthy with a life expectancy greater than 10 years.
Screening and overdiagnosis
Overdiagnosis – the diagnosis of cancers that may not actually cause mortality or may not even have become apparent without screening – is a concern for all women undergoing routine screening for breast cancer. There is significant uncertainty about its frequency, however.
Research cited by the USPSTF suggests that as many as one in five women diagnosed with breast cancer over approximately 10 years will be overdiagnosed. Other modeling studies have estimated one in eight overdiagnoses, for women aged 50-75 years specifically. By the more conservative estimate, according to the USPSTF, one breast cancer death will be prevented for every 2-3 cases of unnecessary treatment.2
Ductal carcinoma in situ is confined to the mammary ductal-lobular system and lacks the classic characteristics of cancer. Technically, it should not metastasize. But we do not know with certainty which cases of DCIS will or will not progress to invasive cancer. Therefore these women often are offered surgical approaches mirroring invasive cancer treatments (lumpectomy with radiation or even mastectomy in some cases), while for some, such treatments may be unnecessary.
Screening younger women (40-49)
Shared decision-making is always important for breast cancer screening, but in our program we routinely recommend annual screening in average-risk women starting at age 40 for several reasons. For one, younger women may present with more aggressive types of breast cancer such as triple-negative breast cancer. These are much less common than hormone-receptor positive breast cancers – they represent 15%-20% of all breast cancers – but they are faster growing and may develop in the interim if women are screened less often (at 2-year intervals).
In addition, finding an invasive breast cancer early is almost always beneficial. Earlier diagnosis (lower stage at diagnosis) is associated with increased breast cancer-specific and overall survival, as well as less-aggressive treatment approaches.
As a medical oncologist who treats women with breast cancer, I see these benefits firsthand. With earlier diagnosis, we are more likely to offer less aggressive surgical approaches such as partial mastectomy (lumpectomy) and sentinel lymph node biopsy as opposed to total mastectomy with axillary lymph node dissection, the latter of which is more likely to be associated with lymphedema and which can lead to postmastectomy chest wall pain syndromes.
We also are able to use less aggressive radiation therapy approaches such as partial breast radiation, and less aggressive breast cancer–specific systemic treatments for women with a lower stage of breast cancer at diagnosis. In some cases, adjuvant or neoadjuvant chemotherapy may not be needed – and when it is necessary, shorter courses of chemotherapy or targeted chemotherapeutic regimens may be offered. This means lower systemic toxicities, both early and late, such as less cytopenias, risk of infections, mucositis, hair loss, cardiotoxicity, secondary malignancies/leukemia, and peripheral sensory neuropathy.
It is important to note that Black women in the United States have the highest death rate from breast cancer – 27.3 per 100,000 per year, versus 19.6 per 100,000 per year for White women1 – and that younger Black women appear to have a higher risk of developing triple-negative breast cancer, a more aggressive type of breast cancer. The higher breast cancer mortality in Black women is likely multifactorial and may be attributed partly to disparities in health care and partly to tumor biology. The case for annual screening in this population thus seems especially strong.
Screening modalities
Digital 3-D mammography, or digital breast tomosynthesis (DBT), is widely considered to be a more sensitive screening tool than conventional digital mammography alone. The NCCN recommends DBT for women with an average risk of developing breast cancer starting at age 40,4,5 and the USPSTF, while offering no recommendation on DBT as a primary screening method (“insufficient evidence”), says that DBT appears to increase cancer detection rates.2 So, I do routinely recommend it.
DBT may be especially beneficial for women with dense breast tissue (determined mammographically), who are most often premenopausal women – particularly non-Hispanic White women. Dense breast tissue itself can contribute to an increased risk of breast cancer – an approximately 20% higher relative risk in an average-risk woman with heterogeneously dense breast tissue, and an approximately 100% higher relative risk in a woman with extremely dense breasts6 – but unfortunately it affects the sensitivity and specificity of screening mammography.
I do not recommend routine supplemental screening with other methods (breast ultrasonography or MRI) for women at average risk of breast cancer who have dense breasts. MRI with gadolinium contrast is recommended as an adjunct to mammography for women who have a lifetime risk of developing breast cancer of more than 20%-25% (e.g., women with known BRCA1/2 mutations or radiation to breast tissue), and can be done annually at the same time as the screening mammogram is done. Some clinicians and patients prefer to alternate these two tests – one every 6 months.
Screening breast MRI is more sensitive but less specific than mammography; combining the two screening modalities leads to overall increased sensitivity and specificity in high-risk populations.
Risk assessment
Identifying higher-risk women who need to be sent to a genetic counselor is critically important. The USPSTF recommends that women who have family members with breast, ovarian, tubal or peritoneal cancer, or who have an ancestry associated with BRCA1/2 gene mutations, be assessed with a brief familial risk assessment tool such as the Pedigree Assessment Tool. This and other validated tools have been evaluated by the USPSTF and can be used to guide referrals to genetic counseling for more definitive risk assessment.7
These tools are different from general breast cancer risk assessment models, such as the NCI’s Breast Cancer Risk Assessment Tool,8 which are designed to calculate the 5-year and lifetime risk of developing invasive breast cancer for an average-risk woman but not to identify BRCA-related cancer risk. (The NCI’s tool is based on the Gail model, which has been widely used over the years.)
The general risk assessment models use a women’s personal medical and reproductive history as well as the history of breast cancer among her first-degree relatives to estimate her risk.
Dr. Tkaczuk reported that she has no disclosures.
References
1. “Cancer Stat Facts: Female Breast Cancer.” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
2. Siu AL et al. Ann Intern Med. 2016 Feb 16. doi: 10.7326/M15-2886.
3. Independent UK Panel on Breast Cancer Screening. Lancet. 2012 Nov 17;380(9855):1778-86.
4. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Screening and Diagnosis. National Comprehensive Cancer Network.
5. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Risk Reduction. National Comprehensive Cancer Network.
6. Ziv E et al. Cancer Epidemiol Biomarkers Prev. 2004;13(12):2090-5.
7. USPSTF. JAMA. 2019;322(7):652-65.
8. The Breast Cancer Risk Assessment Tool. National Cancer Institute.
Screening mammography has contributed to the lowering of mortality from breast cancer by facilitating earlier diagnosis and a lower stage at diagnosis. With more effective treatment options for women who are diagnosed with lower-stage breast cancer, the current 5-year survival rate has risen to 90% – significantly higher than the 5-year survival rate of 75% in 1975.1
Women who are at much higher risk for developing breast cancer – mainly because of family history, certain genetic mutations, or a history of radiation therapy to the chest – will benefit the most from earlier and more frequent screening mammography as well as enhanced screening with non-x-ray methods of breast imaging. It is important that ob.gyns. help to identify these women.
However, the majority of women who are screened with mammography are at “average risk,” with a lifetime risk for developing breast cancer of 12.9%, based on 2015-2017 data from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results Program (SEER).1 The median age at diagnosis of breast cancer in the U.S. is 62 years,1 and advancing age is the most important risk factor for these women.
A 20% relative risk reduction in breast cancer mortality with screening mammography has been demonstrated both in systematic reviews of randomized and observational studies2 and in a meta-analysis of 11 randomized trials comparing screening and no screening.3 Even though the majority of randomized trials were done in the age of film mammography, experts believe that we still see at least a 20% reduction today.
Among average-risk women, those aged 50-74 with a life expectancy of at least 10 years will benefit the most from regular screening. According to the 2016 screening guideline of the United States Preventive Services Task Force (USPSTF), relative risk reductions in breast cancer mortality from mammography screening, by age group, are 0.88 (confidence interval, 0.73-1.003) for ages 39-49; 0.86 (CI, 0.68-0.97) for ages 50-59; 0.67 (CI, 0.55-0.91) for ages 60-69; and 0.80 (CI, 0.51 to 1.28) for ages 70-74.2
For women aged 40-49 years, most of the guidelines in the United States recommend individualized screening every 1 or 2 years – screening that is guided by shared decision-making that takes into account each woman’s values regarding relative harms and benefits. This is because their risk of developing breast cancer is relatively low while the risk of false-positive results can be higher.
A few exceptions include guidelines by the National Comprehensive Cancer Network (NCCN) and the American College of Radiology, which recommend annual screening mammography starting at age 40 years for all average-risk women. In our program, we adhere to these latter recommendations and advise annual digital 3-D mammograms starting at age 40 and continuing until age 74, or longer if the woman is otherwise healthy with a life expectancy greater than 10 years.
Screening and overdiagnosis
Overdiagnosis – the diagnosis of cancers that may not actually cause mortality or may not even have become apparent without screening – is a concern for all women undergoing routine screening for breast cancer. There is significant uncertainty about its frequency, however.
Research cited by the USPSTF suggests that as many as one in five women diagnosed with breast cancer over approximately 10 years will be overdiagnosed. Other modeling studies have estimated one in eight overdiagnoses, for women aged 50-75 years specifically. By the more conservative estimate, according to the USPSTF, one breast cancer death will be prevented for every 2-3 cases of unnecessary treatment.2
Ductal carcinoma in situ is confined to the mammary ductal-lobular system and lacks the classic characteristics of cancer. Technically, it should not metastasize. But we do not know with certainty which cases of DCIS will or will not progress to invasive cancer. Therefore these women often are offered surgical approaches mirroring invasive cancer treatments (lumpectomy with radiation or even mastectomy in some cases), while for some, such treatments may be unnecessary.
Screening younger women (40-49)
Shared decision-making is always important for breast cancer screening, but in our program we routinely recommend annual screening in average-risk women starting at age 40 for several reasons. For one, younger women may present with more aggressive types of breast cancer such as triple-negative breast cancer. These are much less common than hormone-receptor positive breast cancers – they represent 15%-20% of all breast cancers – but they are faster growing and may develop in the interim if women are screened less often (at 2-year intervals).
In addition, finding an invasive breast cancer early is almost always beneficial. Earlier diagnosis (lower stage at diagnosis) is associated with increased breast cancer-specific and overall survival, as well as less-aggressive treatment approaches.
As a medical oncologist who treats women with breast cancer, I see these benefits firsthand. With earlier diagnosis, we are more likely to offer less aggressive surgical approaches such as partial mastectomy (lumpectomy) and sentinel lymph node biopsy as opposed to total mastectomy with axillary lymph node dissection, the latter of which is more likely to be associated with lymphedema and which can lead to postmastectomy chest wall pain syndromes.
We also are able to use less aggressive radiation therapy approaches such as partial breast radiation, and less aggressive breast cancer–specific systemic treatments for women with a lower stage of breast cancer at diagnosis. In some cases, adjuvant or neoadjuvant chemotherapy may not be needed – and when it is necessary, shorter courses of chemotherapy or targeted chemotherapeutic regimens may be offered. This means lower systemic toxicities, both early and late, such as less cytopenias, risk of infections, mucositis, hair loss, cardiotoxicity, secondary malignancies/leukemia, and peripheral sensory neuropathy.
It is important to note that Black women in the United States have the highest death rate from breast cancer – 27.3 per 100,000 per year, versus 19.6 per 100,000 per year for White women1 – and that younger Black women appear to have a higher risk of developing triple-negative breast cancer, a more aggressive type of breast cancer. The higher breast cancer mortality in Black women is likely multifactorial and may be attributed partly to disparities in health care and partly to tumor biology. The case for annual screening in this population thus seems especially strong.
Screening modalities
Digital 3-D mammography, or digital breast tomosynthesis (DBT), is widely considered to be a more sensitive screening tool than conventional digital mammography alone. The NCCN recommends DBT for women with an average risk of developing breast cancer starting at age 40,4,5 and the USPSTF, while offering no recommendation on DBT as a primary screening method (“insufficient evidence”), says that DBT appears to increase cancer detection rates.2 So, I do routinely recommend it.
DBT may be especially beneficial for women with dense breast tissue (determined mammographically), who are most often premenopausal women – particularly non-Hispanic White women. Dense breast tissue itself can contribute to an increased risk of breast cancer – an approximately 20% higher relative risk in an average-risk woman with heterogeneously dense breast tissue, and an approximately 100% higher relative risk in a woman with extremely dense breasts6 – but unfortunately it affects the sensitivity and specificity of screening mammography.
I do not recommend routine supplemental screening with other methods (breast ultrasonography or MRI) for women at average risk of breast cancer who have dense breasts. MRI with gadolinium contrast is recommended as an adjunct to mammography for women who have a lifetime risk of developing breast cancer of more than 20%-25% (e.g., women with known BRCA1/2 mutations or radiation to breast tissue), and can be done annually at the same time as the screening mammogram is done. Some clinicians and patients prefer to alternate these two tests – one every 6 months.
Screening breast MRI is more sensitive but less specific than mammography; combining the two screening modalities leads to overall increased sensitivity and specificity in high-risk populations.
Risk assessment
Identifying higher-risk women who need to be sent to a genetic counselor is critically important. The USPSTF recommends that women who have family members with breast, ovarian, tubal or peritoneal cancer, or who have an ancestry associated with BRCA1/2 gene mutations, be assessed with a brief familial risk assessment tool such as the Pedigree Assessment Tool. This and other validated tools have been evaluated by the USPSTF and can be used to guide referrals to genetic counseling for more definitive risk assessment.7
These tools are different from general breast cancer risk assessment models, such as the NCI’s Breast Cancer Risk Assessment Tool,8 which are designed to calculate the 5-year and lifetime risk of developing invasive breast cancer for an average-risk woman but not to identify BRCA-related cancer risk. (The NCI’s tool is based on the Gail model, which has been widely used over the years.)
The general risk assessment models use a women’s personal medical and reproductive history as well as the history of breast cancer among her first-degree relatives to estimate her risk.
Dr. Tkaczuk reported that she has no disclosures.
References
1. “Cancer Stat Facts: Female Breast Cancer.” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
2. Siu AL et al. Ann Intern Med. 2016 Feb 16. doi: 10.7326/M15-2886.
3. Independent UK Panel on Breast Cancer Screening. Lancet. 2012 Nov 17;380(9855):1778-86.
4. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Screening and Diagnosis. National Comprehensive Cancer Network.
5. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Risk Reduction. National Comprehensive Cancer Network.
6. Ziv E et al. Cancer Epidemiol Biomarkers Prev. 2004;13(12):2090-5.
7. USPSTF. JAMA. 2019;322(7):652-65.
8. The Breast Cancer Risk Assessment Tool. National Cancer Institute.
Geriatric patients: My three rules for them
I have been in practice for 31 years, so many of my patients are now in their 80s and 90s. Practices age with us, and I have been seeing many of these patients for 25-30 years.
Absolutely, positively make sure you move!
Our older patients often have many reasons not to move, including pain from arthritis, deconditioning, muscle weakness, fatigue, and depression. “Keeping moving” is probably the most important thing a patient can do for their health.
Holme and Anderssen studied a large cohort of men for cardiovascular risk in 1972 and again in 2000. The surviving men were followed over an additional 12 years.1 They found that 30 minutes of physical activity 6 days a week was associated with a 40% reduction in mortality. Sedentary men had a reduced life expectancy of about 5 years, compared with men who were moderately to vigorously physically active.
Stewart etal. studied the benefit of physical activity in people with stable coronary disease.2 They concluded that, in patients with stable coronary heart disease, more physical activity was associated with lower mortality, and the largest benefit occurred in the sedentary patient groups and the highest cardiac risk groups.
Saint-Maurice et al. studied the effects of total daily step count and step intensity on mortality risk.3 They found that the risk of all-cause mortality decreases as the total number of daily steps increases, but that the speed of those steps did not make a difference. This is very encouraging data for our elderly patients. Moving is the secret, even if it may not be moving at a fast pace!
Never, ever get on a ladder!
This one should be part of every geriatric’s assessment and every Medicare wellness exam. I first experienced the horror of what can happen when elderly people climb when a 96-year-old healthy patient of mine fell off his roof and died. I never thought to tell him climbing on the roof was an awful idea.
Akland et al. looked at the epidemiology and outcomes of ladder-related falls that required ICU admission.4 Hospital mortality was 26%, and almost all of the mortalities occurred in older males in domestic falls, who died as a result of traumatic brain injury. Fewer than half of the survivors were living independently 1 year after the fall.
Valmuur et al. studied ladder related falls in Australia.5 They found that rates of ladder related falls requiring hospitalization rose from about 20/100,000 for men ages 15-29 years to 78/100,000 for men aged over 60 years. Of those who died from fall-related injury, 82% were over the age of 60, with more than 70% dying from head injuries.
Schaffarczyk et al. looked at the impact of nonoccupational falls from ladders in men aged over 50 years.6 The mean age of the patients in the study was 64 years (range, 50-85), with 27% suffering severe trauma. There was a striking impact on long-term function occurring in over half the study patients. The authors did interviews with patients in follow-up long after the falls and found that most never thought of themselves at risk for a fall, and after the experience of a bad fall, would never consider going on a ladder again. I think it is important for health care professionals to discuss the dangers of ladder use with our older patients, pointing out the higher risk of falling and the potential for the fall to be a life-changing or life-ending event.
Let them eat!
Many patients have a reduced appetite as they age. We work hard with our patients to choose a healthy diet throughout their lives, to help ward off obesity, treat hypertension, prevent or control diabetes, or provide heart health. Many patients just stop being interested in food, reduce intake, and may lose weight and muscle mass. When my patients pass the age of 85, I change my focus to encouraging them to eat for calories, socialization, and joy. I think the marginal benefits of more restrictive diets are small, compared with the benefits of helping your patients enjoy eating again. I ask patients what their very favorite foods are and encourage them to have them.
Pearl
Keep your patients eating and moving, except not onto a ladder!
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. Holme I, Anderssen SA. Increases in physical activity is as important as smoking cessation for reduction in total mortality in elderly men: 12 years of follow-up of the Oslo II study. Br J Sports Med. 2015; 49:743-8.
2. Stewart RAH et al. Physical activity and mortality in patients with stable coronary heart disease. J Am Coll Cardiol. 2017 Oct 3;70(14):1689-1700..
3. Saint-Maurice PF et al. Association of daily step count and step intensity with mortality among U.S. adults. JAMA 2020;323:1151-60.
4. Ackland HM et al. Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma. Injury. 2016;47:1109-117.
5. Vallmuur K et al. Falls from ladders in Australia: comparing occupational and nonoccupational injuries across age groups. Aust N Z J Public Health. 2016 Dec;40(6):559-63.
6. Schaffarczyk K et al. Nonoccupational falls from ladders in men 50 years and over: Contributing factors and impact. Injury. 2020 Aug;51(8):1798-1804.
I have been in practice for 31 years, so many of my patients are now in their 80s and 90s. Practices age with us, and I have been seeing many of these patients for 25-30 years.
Absolutely, positively make sure you move!
Our older patients often have many reasons not to move, including pain from arthritis, deconditioning, muscle weakness, fatigue, and depression. “Keeping moving” is probably the most important thing a patient can do for their health.
Holme and Anderssen studied a large cohort of men for cardiovascular risk in 1972 and again in 2000. The surviving men were followed over an additional 12 years.1 They found that 30 minutes of physical activity 6 days a week was associated with a 40% reduction in mortality. Sedentary men had a reduced life expectancy of about 5 years, compared with men who were moderately to vigorously physically active.
Stewart etal. studied the benefit of physical activity in people with stable coronary disease.2 They concluded that, in patients with stable coronary heart disease, more physical activity was associated with lower mortality, and the largest benefit occurred in the sedentary patient groups and the highest cardiac risk groups.
Saint-Maurice et al. studied the effects of total daily step count and step intensity on mortality risk.3 They found that the risk of all-cause mortality decreases as the total number of daily steps increases, but that the speed of those steps did not make a difference. This is very encouraging data for our elderly patients. Moving is the secret, even if it may not be moving at a fast pace!
Never, ever get on a ladder!
This one should be part of every geriatric’s assessment and every Medicare wellness exam. I first experienced the horror of what can happen when elderly people climb when a 96-year-old healthy patient of mine fell off his roof and died. I never thought to tell him climbing on the roof was an awful idea.
Akland et al. looked at the epidemiology and outcomes of ladder-related falls that required ICU admission.4 Hospital mortality was 26%, and almost all of the mortalities occurred in older males in domestic falls, who died as a result of traumatic brain injury. Fewer than half of the survivors were living independently 1 year after the fall.
Valmuur et al. studied ladder related falls in Australia.5 They found that rates of ladder related falls requiring hospitalization rose from about 20/100,000 for men ages 15-29 years to 78/100,000 for men aged over 60 years. Of those who died from fall-related injury, 82% were over the age of 60, with more than 70% dying from head injuries.
Schaffarczyk et al. looked at the impact of nonoccupational falls from ladders in men aged over 50 years.6 The mean age of the patients in the study was 64 years (range, 50-85), with 27% suffering severe trauma. There was a striking impact on long-term function occurring in over half the study patients. The authors did interviews with patients in follow-up long after the falls and found that most never thought of themselves at risk for a fall, and after the experience of a bad fall, would never consider going on a ladder again. I think it is important for health care professionals to discuss the dangers of ladder use with our older patients, pointing out the higher risk of falling and the potential for the fall to be a life-changing or life-ending event.
Let them eat!
Many patients have a reduced appetite as they age. We work hard with our patients to choose a healthy diet throughout their lives, to help ward off obesity, treat hypertension, prevent or control diabetes, or provide heart health. Many patients just stop being interested in food, reduce intake, and may lose weight and muscle mass. When my patients pass the age of 85, I change my focus to encouraging them to eat for calories, socialization, and joy. I think the marginal benefits of more restrictive diets are small, compared with the benefits of helping your patients enjoy eating again. I ask patients what their very favorite foods are and encourage them to have them.
Pearl
Keep your patients eating and moving, except not onto a ladder!
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. Holme I, Anderssen SA. Increases in physical activity is as important as smoking cessation for reduction in total mortality in elderly men: 12 years of follow-up of the Oslo II study. Br J Sports Med. 2015; 49:743-8.
2. Stewart RAH et al. Physical activity and mortality in patients with stable coronary heart disease. J Am Coll Cardiol. 2017 Oct 3;70(14):1689-1700..
3. Saint-Maurice PF et al. Association of daily step count and step intensity with mortality among U.S. adults. JAMA 2020;323:1151-60.
4. Ackland HM et al. Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma. Injury. 2016;47:1109-117.
5. Vallmuur K et al. Falls from ladders in Australia: comparing occupational and nonoccupational injuries across age groups. Aust N Z J Public Health. 2016 Dec;40(6):559-63.
6. Schaffarczyk K et al. Nonoccupational falls from ladders in men 50 years and over: Contributing factors and impact. Injury. 2020 Aug;51(8):1798-1804.
I have been in practice for 31 years, so many of my patients are now in their 80s and 90s. Practices age with us, and I have been seeing many of these patients for 25-30 years.
Absolutely, positively make sure you move!
Our older patients often have many reasons not to move, including pain from arthritis, deconditioning, muscle weakness, fatigue, and depression. “Keeping moving” is probably the most important thing a patient can do for their health.
Holme and Anderssen studied a large cohort of men for cardiovascular risk in 1972 and again in 2000. The surviving men were followed over an additional 12 years.1 They found that 30 minutes of physical activity 6 days a week was associated with a 40% reduction in mortality. Sedentary men had a reduced life expectancy of about 5 years, compared with men who were moderately to vigorously physically active.
Stewart etal. studied the benefit of physical activity in people with stable coronary disease.2 They concluded that, in patients with stable coronary heart disease, more physical activity was associated with lower mortality, and the largest benefit occurred in the sedentary patient groups and the highest cardiac risk groups.
Saint-Maurice et al. studied the effects of total daily step count and step intensity on mortality risk.3 They found that the risk of all-cause mortality decreases as the total number of daily steps increases, but that the speed of those steps did not make a difference. This is very encouraging data for our elderly patients. Moving is the secret, even if it may not be moving at a fast pace!
Never, ever get on a ladder!
This one should be part of every geriatric’s assessment and every Medicare wellness exam. I first experienced the horror of what can happen when elderly people climb when a 96-year-old healthy patient of mine fell off his roof and died. I never thought to tell him climbing on the roof was an awful idea.
Akland et al. looked at the epidemiology and outcomes of ladder-related falls that required ICU admission.4 Hospital mortality was 26%, and almost all of the mortalities occurred in older males in domestic falls, who died as a result of traumatic brain injury. Fewer than half of the survivors were living independently 1 year after the fall.
Valmuur et al. studied ladder related falls in Australia.5 They found that rates of ladder related falls requiring hospitalization rose from about 20/100,000 for men ages 15-29 years to 78/100,000 for men aged over 60 years. Of those who died from fall-related injury, 82% were over the age of 60, with more than 70% dying from head injuries.
Schaffarczyk et al. looked at the impact of nonoccupational falls from ladders in men aged over 50 years.6 The mean age of the patients in the study was 64 years (range, 50-85), with 27% suffering severe trauma. There was a striking impact on long-term function occurring in over half the study patients. The authors did interviews with patients in follow-up long after the falls and found that most never thought of themselves at risk for a fall, and after the experience of a bad fall, would never consider going on a ladder again. I think it is important for health care professionals to discuss the dangers of ladder use with our older patients, pointing out the higher risk of falling and the potential for the fall to be a life-changing or life-ending event.
Let them eat!
Many patients have a reduced appetite as they age. We work hard with our patients to choose a healthy diet throughout their lives, to help ward off obesity, treat hypertension, prevent or control diabetes, or provide heart health. Many patients just stop being interested in food, reduce intake, and may lose weight and muscle mass. When my patients pass the age of 85, I change my focus to encouraging them to eat for calories, socialization, and joy. I think the marginal benefits of more restrictive diets are small, compared with the benefits of helping your patients enjoy eating again. I ask patients what their very favorite foods are and encourage them to have them.
Pearl
Keep your patients eating and moving, except not onto a ladder!
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. Holme I, Anderssen SA. Increases in physical activity is as important as smoking cessation for reduction in total mortality in elderly men: 12 years of follow-up of the Oslo II study. Br J Sports Med. 2015; 49:743-8.
2. Stewart RAH et al. Physical activity and mortality in patients with stable coronary heart disease. J Am Coll Cardiol. 2017 Oct 3;70(14):1689-1700..
3. Saint-Maurice PF et al. Association of daily step count and step intensity with mortality among U.S. adults. JAMA 2020;323:1151-60.
4. Ackland HM et al. Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma. Injury. 2016;47:1109-117.
5. Vallmuur K et al. Falls from ladders in Australia: comparing occupational and nonoccupational injuries across age groups. Aust N Z J Public Health. 2016 Dec;40(6):559-63.
6. Schaffarczyk K et al. Nonoccupational falls from ladders in men 50 years and over: Contributing factors and impact. Injury. 2020 Aug;51(8):1798-1804.
The scope of under- and overtreatment in older adults with cancer
Because of physiological changes with aging and differences in cancer biology, caring for older adults (OAs) with cancer requires careful assessment and planning.
Clark Dumontier, MD, of Brigham and Women’s Hospital in Boston, and colleagues sought to define the meaning of the terms “undertreatment” and “overtreatment” for OAs with cancer in a scoping literature review published in the Journal of Clinical Oncology.
Though OAs are typically defined as adults aged 65 years and older, in this review, the authors defined OAs as patients aged 60 years and older.
The authors theorized that a scoping review of papers about this patient population could provide clues about limitations in the oncology literature and guidance about patient management and future research. Despite comprising the majority of cancer patients, OAs are underrepresented in clinical trials.
About scoping reviews
Scoping reviews are used to identify existing evidence in a field, clarify concepts or definitions in the literature, survey how research on a topic is conducted, and identify knowledge gaps. In addition, scoping reviews summarize available evidence without answering a discrete research question.
Industry standards for scoping reviews have been established by the Johanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews. According to these standards, scoping reviews should:
- Establish eligibility criteria with a rationale for each criterion clearly explained
- Search multiple databases in multiple languages
- Include “gray literature,” defined as studies that are unpublished or difficult to locate
- Have several independent reviewers screen titles and abstracts
- Ask multiple independent reviewers to review full text articles
- Present results with charts or diagrams that align with the review’s objective
- Graphically depict the decision process for including/excluding sources
- Identify implications for further research.
In their review, Dr. DuMontier and colleagues fulfilled many of the aforementioned criteria. The team searched three English-language databases for titles and abstracts that included the terms undertreatment and/or overtreatment, and were related to OAs with cancer, inclusive of all types of articles, cancer types, and treatments.
Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived. Within a random subset of articles, two coauthors independently determined final categories of definitions and independently assigned those categories.
Findings and implications
To define OA, Dr. DuMontier and colleagues used a cutoff of 60 years or older. Articles mentioning undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion (n = 256), but only 14 articles (5.5%) explicitly provided formal definitions.
For most of the reviewed articles, the authors judged definitions from the surrounding context. In a random subset of 50 articles, there was a high level of agreement (87.1%; κ = 0.81) between two coauthors in independently assigning categories of definitions.
Undertreatment was applied to therapy that was less than recommended (148 articles; 62.7%) or less than recommended with worse outcomes (88 articles; 37.3%).
Overtreatment most commonly denoted intensive treatment of an OA in whom harms outweighed the benefits of treatment (38 articles; 53.5%) or intensive treatment of a cancer not expected to affect the OA during the patient’s remaining life (33 articles; 46.5%).
Overall, the authors found that undertreatment and overtreatment of OAs with cancer are imprecisely defined concepts. Formal geriatric assessment was recommended in just over half of articles, and only 26.2% recommended formal assessments of age-related vulnerabilities for management. The authors proposed definitions that accounted for both oncologic factors and geriatric domains.
Care of individual patients and clinical research
National Comprehensive Cancer Network (NCCN) guidelines for OAs with cancer recommend initial consideration of overall life expectancy. If a patient is a candidate for cancer treatment on that basis, the next recommended assessment is that of the patient’s capacity to understand the relevant information, appreciate the underlying values and overall medical situation, reason through decisions, and communicate a choice that is consistent with the patient’s articulated goals.
In the pretreatment evaluation of OAs in whom there are no concerns about tolerance to antineoplastic therapy, NCCN guidelines suggest geriatric screening with standardized tools and, if abnormal, comprehensive geriatric screening. The guidelines recommend considering alternative treatment options if nonmodifiable abnormalities are identified.
Referral to a geriatric clinical specialist, use of the Cancer and Aging Research Group’s Chemo Toxicity Calculator, and calculation of Chemotherapy Risk Assessment Scale for High-Age Patients score are specifically suggested if high-risk procedures (such as chemotherapy, radiation, or complex surgery, which most oncologists would consider to be “another day in the office”) are contemplated.
The American Society of Clinical Oncology (ASCO) guidelines for geriatric oncology are similarly detailed and endorse similar evaluations and management.
Employing disease-centric and geriatric domains
Dr. DuMontier and colleagues noted that, for OAs with comorbidity or psychosocial challenges, surrogate survival endpoints are unrelated to quality of life (QOL) outcomes. Nonetheless, QOL is valued by OAs at least as much as survival improvement.
Through no fault of their own, the authors’ conclusion that undertreatment and overtreatment are imperfectly defined concepts has a certain neutrality to it. However, the terms undertreatment and overtreatment are commonly used to signify that inappropriate treatment decisions were made. Therefore, the terms are inherently negative and pejorative.
As with most emotionally charged issues in oncology, it is ideal for professionals in our field to take charge when deficiencies exist. ASCO, NCCN, and the authors of this scoping review have provided a conceptual basis for doing so.
An integrated oncologist-geriatrician approach was shown to be effective in the randomized INTEGERATE trial, showing improved QOL, reduced hospital admissions, and reduced early treatment discontinuation from adverse events (ASCO 2020, Abstract 12011).
Therefore, those clinicians who have not formally, systematically, and routinely supplemented the traditional disease-centric endpoints with patient-centered criteria need to do so.
Similarly, a retrospective study published in JAMA Network Open demonstrated that geriatric and surgical comanagement of OAs with cancer was associated with significantly lower 90-day postoperative mortality and receipt of more supportive care services (physical therapy, occupational therapy, speech and swallow rehabilitation, and nutrition services), in comparison with management from the surgical service only.
These clinical and administrative changes will not only enhance patient management but also facilitate the clinical trials required to clarify optimal treatment intensity. As that occurs, we will be able to apply as much precision to the care of OAs with cancer as we do in other areas of cancer treatment.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
SOURCE: Dumontier C et al. J Clin Oncol. 2020 Aug 1;38(22):2558-2569.
Because of physiological changes with aging and differences in cancer biology, caring for older adults (OAs) with cancer requires careful assessment and planning.
Clark Dumontier, MD, of Brigham and Women’s Hospital in Boston, and colleagues sought to define the meaning of the terms “undertreatment” and “overtreatment” for OAs with cancer in a scoping literature review published in the Journal of Clinical Oncology.
Though OAs are typically defined as adults aged 65 years and older, in this review, the authors defined OAs as patients aged 60 years and older.
The authors theorized that a scoping review of papers about this patient population could provide clues about limitations in the oncology literature and guidance about patient management and future research. Despite comprising the majority of cancer patients, OAs are underrepresented in clinical trials.
About scoping reviews
Scoping reviews are used to identify existing evidence in a field, clarify concepts or definitions in the literature, survey how research on a topic is conducted, and identify knowledge gaps. In addition, scoping reviews summarize available evidence without answering a discrete research question.
Industry standards for scoping reviews have been established by the Johanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews. According to these standards, scoping reviews should:
- Establish eligibility criteria with a rationale for each criterion clearly explained
- Search multiple databases in multiple languages
- Include “gray literature,” defined as studies that are unpublished or difficult to locate
- Have several independent reviewers screen titles and abstracts
- Ask multiple independent reviewers to review full text articles
- Present results with charts or diagrams that align with the review’s objective
- Graphically depict the decision process for including/excluding sources
- Identify implications for further research.
In their review, Dr. DuMontier and colleagues fulfilled many of the aforementioned criteria. The team searched three English-language databases for titles and abstracts that included the terms undertreatment and/or overtreatment, and were related to OAs with cancer, inclusive of all types of articles, cancer types, and treatments.
Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived. Within a random subset of articles, two coauthors independently determined final categories of definitions and independently assigned those categories.
Findings and implications
To define OA, Dr. DuMontier and colleagues used a cutoff of 60 years or older. Articles mentioning undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion (n = 256), but only 14 articles (5.5%) explicitly provided formal definitions.
For most of the reviewed articles, the authors judged definitions from the surrounding context. In a random subset of 50 articles, there was a high level of agreement (87.1%; κ = 0.81) between two coauthors in independently assigning categories of definitions.
Undertreatment was applied to therapy that was less than recommended (148 articles; 62.7%) or less than recommended with worse outcomes (88 articles; 37.3%).
Overtreatment most commonly denoted intensive treatment of an OA in whom harms outweighed the benefits of treatment (38 articles; 53.5%) or intensive treatment of a cancer not expected to affect the OA during the patient’s remaining life (33 articles; 46.5%).
Overall, the authors found that undertreatment and overtreatment of OAs with cancer are imprecisely defined concepts. Formal geriatric assessment was recommended in just over half of articles, and only 26.2% recommended formal assessments of age-related vulnerabilities for management. The authors proposed definitions that accounted for both oncologic factors and geriatric domains.
Care of individual patients and clinical research
National Comprehensive Cancer Network (NCCN) guidelines for OAs with cancer recommend initial consideration of overall life expectancy. If a patient is a candidate for cancer treatment on that basis, the next recommended assessment is that of the patient’s capacity to understand the relevant information, appreciate the underlying values and overall medical situation, reason through decisions, and communicate a choice that is consistent with the patient’s articulated goals.
In the pretreatment evaluation of OAs in whom there are no concerns about tolerance to antineoplastic therapy, NCCN guidelines suggest geriatric screening with standardized tools and, if abnormal, comprehensive geriatric screening. The guidelines recommend considering alternative treatment options if nonmodifiable abnormalities are identified.
Referral to a geriatric clinical specialist, use of the Cancer and Aging Research Group’s Chemo Toxicity Calculator, and calculation of Chemotherapy Risk Assessment Scale for High-Age Patients score are specifically suggested if high-risk procedures (such as chemotherapy, radiation, or complex surgery, which most oncologists would consider to be “another day in the office”) are contemplated.
The American Society of Clinical Oncology (ASCO) guidelines for geriatric oncology are similarly detailed and endorse similar evaluations and management.
Employing disease-centric and geriatric domains
Dr. DuMontier and colleagues noted that, for OAs with comorbidity or psychosocial challenges, surrogate survival endpoints are unrelated to quality of life (QOL) outcomes. Nonetheless, QOL is valued by OAs at least as much as survival improvement.
Through no fault of their own, the authors’ conclusion that undertreatment and overtreatment are imperfectly defined concepts has a certain neutrality to it. However, the terms undertreatment and overtreatment are commonly used to signify that inappropriate treatment decisions were made. Therefore, the terms are inherently negative and pejorative.
As with most emotionally charged issues in oncology, it is ideal for professionals in our field to take charge when deficiencies exist. ASCO, NCCN, and the authors of this scoping review have provided a conceptual basis for doing so.
An integrated oncologist-geriatrician approach was shown to be effective in the randomized INTEGERATE trial, showing improved QOL, reduced hospital admissions, and reduced early treatment discontinuation from adverse events (ASCO 2020, Abstract 12011).
Therefore, those clinicians who have not formally, systematically, and routinely supplemented the traditional disease-centric endpoints with patient-centered criteria need to do so.
Similarly, a retrospective study published in JAMA Network Open demonstrated that geriatric and surgical comanagement of OAs with cancer was associated with significantly lower 90-day postoperative mortality and receipt of more supportive care services (physical therapy, occupational therapy, speech and swallow rehabilitation, and nutrition services), in comparison with management from the surgical service only.
These clinical and administrative changes will not only enhance patient management but also facilitate the clinical trials required to clarify optimal treatment intensity. As that occurs, we will be able to apply as much precision to the care of OAs with cancer as we do in other areas of cancer treatment.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
SOURCE: Dumontier C et al. J Clin Oncol. 2020 Aug 1;38(22):2558-2569.
Because of physiological changes with aging and differences in cancer biology, caring for older adults (OAs) with cancer requires careful assessment and planning.
Clark Dumontier, MD, of Brigham and Women’s Hospital in Boston, and colleagues sought to define the meaning of the terms “undertreatment” and “overtreatment” for OAs with cancer in a scoping literature review published in the Journal of Clinical Oncology.
Though OAs are typically defined as adults aged 65 years and older, in this review, the authors defined OAs as patients aged 60 years and older.
The authors theorized that a scoping review of papers about this patient population could provide clues about limitations in the oncology literature and guidance about patient management and future research. Despite comprising the majority of cancer patients, OAs are underrepresented in clinical trials.
About scoping reviews
Scoping reviews are used to identify existing evidence in a field, clarify concepts or definitions in the literature, survey how research on a topic is conducted, and identify knowledge gaps. In addition, scoping reviews summarize available evidence without answering a discrete research question.
Industry standards for scoping reviews have been established by the Johanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews. According to these standards, scoping reviews should:
- Establish eligibility criteria with a rationale for each criterion clearly explained
- Search multiple databases in multiple languages
- Include “gray literature,” defined as studies that are unpublished or difficult to locate
- Have several independent reviewers screen titles and abstracts
- Ask multiple independent reviewers to review full text articles
- Present results with charts or diagrams that align with the review’s objective
- Graphically depict the decision process for including/excluding sources
- Identify implications for further research.
In their review, Dr. DuMontier and colleagues fulfilled many of the aforementioned criteria. The team searched three English-language databases for titles and abstracts that included the terms undertreatment and/or overtreatment, and were related to OAs with cancer, inclusive of all types of articles, cancer types, and treatments.
Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived. Within a random subset of articles, two coauthors independently determined final categories of definitions and independently assigned those categories.
Findings and implications
To define OA, Dr. DuMontier and colleagues used a cutoff of 60 years or older. Articles mentioning undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion (n = 256), but only 14 articles (5.5%) explicitly provided formal definitions.
For most of the reviewed articles, the authors judged definitions from the surrounding context. In a random subset of 50 articles, there was a high level of agreement (87.1%; κ = 0.81) between two coauthors in independently assigning categories of definitions.
Undertreatment was applied to therapy that was less than recommended (148 articles; 62.7%) or less than recommended with worse outcomes (88 articles; 37.3%).
Overtreatment most commonly denoted intensive treatment of an OA in whom harms outweighed the benefits of treatment (38 articles; 53.5%) or intensive treatment of a cancer not expected to affect the OA during the patient’s remaining life (33 articles; 46.5%).
Overall, the authors found that undertreatment and overtreatment of OAs with cancer are imprecisely defined concepts. Formal geriatric assessment was recommended in just over half of articles, and only 26.2% recommended formal assessments of age-related vulnerabilities for management. The authors proposed definitions that accounted for both oncologic factors and geriatric domains.
Care of individual patients and clinical research
National Comprehensive Cancer Network (NCCN) guidelines for OAs with cancer recommend initial consideration of overall life expectancy. If a patient is a candidate for cancer treatment on that basis, the next recommended assessment is that of the patient’s capacity to understand the relevant information, appreciate the underlying values and overall medical situation, reason through decisions, and communicate a choice that is consistent with the patient’s articulated goals.
In the pretreatment evaluation of OAs in whom there are no concerns about tolerance to antineoplastic therapy, NCCN guidelines suggest geriatric screening with standardized tools and, if abnormal, comprehensive geriatric screening. The guidelines recommend considering alternative treatment options if nonmodifiable abnormalities are identified.
Referral to a geriatric clinical specialist, use of the Cancer and Aging Research Group’s Chemo Toxicity Calculator, and calculation of Chemotherapy Risk Assessment Scale for High-Age Patients score are specifically suggested if high-risk procedures (such as chemotherapy, radiation, or complex surgery, which most oncologists would consider to be “another day in the office”) are contemplated.
The American Society of Clinical Oncology (ASCO) guidelines for geriatric oncology are similarly detailed and endorse similar evaluations and management.
Employing disease-centric and geriatric domains
Dr. DuMontier and colleagues noted that, for OAs with comorbidity or psychosocial challenges, surrogate survival endpoints are unrelated to quality of life (QOL) outcomes. Nonetheless, QOL is valued by OAs at least as much as survival improvement.
Through no fault of their own, the authors’ conclusion that undertreatment and overtreatment are imperfectly defined concepts has a certain neutrality to it. However, the terms undertreatment and overtreatment are commonly used to signify that inappropriate treatment decisions were made. Therefore, the terms are inherently negative and pejorative.
As with most emotionally charged issues in oncology, it is ideal for professionals in our field to take charge when deficiencies exist. ASCO, NCCN, and the authors of this scoping review have provided a conceptual basis for doing so.
An integrated oncologist-geriatrician approach was shown to be effective in the randomized INTEGERATE trial, showing improved QOL, reduced hospital admissions, and reduced early treatment discontinuation from adverse events (ASCO 2020, Abstract 12011).
Therefore, those clinicians who have not formally, systematically, and routinely supplemented the traditional disease-centric endpoints with patient-centered criteria need to do so.
Similarly, a retrospective study published in JAMA Network Open demonstrated that geriatric and surgical comanagement of OAs with cancer was associated with significantly lower 90-day postoperative mortality and receipt of more supportive care services (physical therapy, occupational therapy, speech and swallow rehabilitation, and nutrition services), in comparison with management from the surgical service only.
These clinical and administrative changes will not only enhance patient management but also facilitate the clinical trials required to clarify optimal treatment intensity. As that occurs, we will be able to apply as much precision to the care of OAs with cancer as we do in other areas of cancer treatment.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
SOURCE: Dumontier C et al. J Clin Oncol. 2020 Aug 1;38(22):2558-2569.
When my patient doesn’t want my help
Since beginning my psychiatry residency, I have come to dread situations in which I feel like the antagonist in my patient’s life. These are moments when, due to psychiatric illness or intoxication, my patient does not want my help. In these situations, the patient’s condition may prevent shared decision-making to determine the best care for them. I experienced such a situation on my first day of residency, and that encounter taught me several valuable lessons.
An anxiety-filled first day
While working with my attending physician in a psychiatric emergency department, we met with a patient who had become agitated and was threatening staff members. The patient was also loudly protesting any use of medications. As a medical student, I had encountered patients who were agitated, but this moment felt vastly different because I was now tasked with addressing the problem. I still remember how my muscles tensed out of anxiety. As the attending took the lead in talking with the patient, the situation continued to escalate. The patient’s agitation was preventing them from being able to safely cooperate with staff despite our efforts at verbal de-escalation. As several staff members stayed with the patient, my attending and I went back to the workroom, where she instructed me to place orders for emergent medications. I sat there, an anxious intern with the solemn power and responsibility to order medications that might need to be administered against the will of an agitated patient. The moment was surreal.
A harsh reality
I had envisioned my first day of residency to be quite different. I had expected to sit with patients, healing them by listening to their stories and giving them the attention they deserved. But instead, I found myself nervously inputting medication orders, checking and rechecking that the doses and administration routes were accurate—all the while knowing that the patient would likely refuse the medications. If that occurred, the patient would need to be held by staff so the medications could be administered. Although I knew that administering emergent medications was the appropriate clinical decision to prevent harm to the patient and others, I felt conflicted by acting in opposition to the patient’s wishes. In that moment, intoxication or illness compromised patient autonomy for the sake of beneficence. I struggled with a creeping sense of guilt.
Although I did not have the chance to interact with this specific patient again, I often reflect on that encounter. I have learned that at times, the use of emergent medications or court commitments for medication administration or hospitalizations is necessary. Since that first shift, I have cared for many other patients who have received emergent medications under similar circumstances. I have observed that such treatment often stabilizes patients and enables me to engage them in meaningful conversation to optimize their care.
Lessons learned
While some of what I have experienced during my training has made me uncomfortable, I have taken with me several valuable lessons. When a patient’s intoxication or illness prevents shared decision-making, our focus as physicians should remain on the patient’s safety, health, and well-being. It is necessary to engage patients in conversations to enable us to understand what ails them and promptly determine the right treatment, tailored to their specific needs and goals.
Moving forward, I know that I will encounter many more similar situations. I hope to position myself quickly and safely alongside agitated patients to engage them in shared decision-making. As a physician, I will approach every encounter with my patients as an opportunity to understand their goals for care, and empower them to make informed decisions regarding their treatment.
Since beginning my psychiatry residency, I have come to dread situations in which I feel like the antagonist in my patient’s life. These are moments when, due to psychiatric illness or intoxication, my patient does not want my help. In these situations, the patient’s condition may prevent shared decision-making to determine the best care for them. I experienced such a situation on my first day of residency, and that encounter taught me several valuable lessons.
An anxiety-filled first day
While working with my attending physician in a psychiatric emergency department, we met with a patient who had become agitated and was threatening staff members. The patient was also loudly protesting any use of medications. As a medical student, I had encountered patients who were agitated, but this moment felt vastly different because I was now tasked with addressing the problem. I still remember how my muscles tensed out of anxiety. As the attending took the lead in talking with the patient, the situation continued to escalate. The patient’s agitation was preventing them from being able to safely cooperate with staff despite our efforts at verbal de-escalation. As several staff members stayed with the patient, my attending and I went back to the workroom, where she instructed me to place orders for emergent medications. I sat there, an anxious intern with the solemn power and responsibility to order medications that might need to be administered against the will of an agitated patient. The moment was surreal.
A harsh reality
I had envisioned my first day of residency to be quite different. I had expected to sit with patients, healing them by listening to their stories and giving them the attention they deserved. But instead, I found myself nervously inputting medication orders, checking and rechecking that the doses and administration routes were accurate—all the while knowing that the patient would likely refuse the medications. If that occurred, the patient would need to be held by staff so the medications could be administered. Although I knew that administering emergent medications was the appropriate clinical decision to prevent harm to the patient and others, I felt conflicted by acting in opposition to the patient’s wishes. In that moment, intoxication or illness compromised patient autonomy for the sake of beneficence. I struggled with a creeping sense of guilt.
Although I did not have the chance to interact with this specific patient again, I often reflect on that encounter. I have learned that at times, the use of emergent medications or court commitments for medication administration or hospitalizations is necessary. Since that first shift, I have cared for many other patients who have received emergent medications under similar circumstances. I have observed that such treatment often stabilizes patients and enables me to engage them in meaningful conversation to optimize their care.
Lessons learned
While some of what I have experienced during my training has made me uncomfortable, I have taken with me several valuable lessons. When a patient’s intoxication or illness prevents shared decision-making, our focus as physicians should remain on the patient’s safety, health, and well-being. It is necessary to engage patients in conversations to enable us to understand what ails them and promptly determine the right treatment, tailored to their specific needs and goals.
Moving forward, I know that I will encounter many more similar situations. I hope to position myself quickly and safely alongside agitated patients to engage them in shared decision-making. As a physician, I will approach every encounter with my patients as an opportunity to understand their goals for care, and empower them to make informed decisions regarding their treatment.
Since beginning my psychiatry residency, I have come to dread situations in which I feel like the antagonist in my patient’s life. These are moments when, due to psychiatric illness or intoxication, my patient does not want my help. In these situations, the patient’s condition may prevent shared decision-making to determine the best care for them. I experienced such a situation on my first day of residency, and that encounter taught me several valuable lessons.
An anxiety-filled first day
While working with my attending physician in a psychiatric emergency department, we met with a patient who had become agitated and was threatening staff members. The patient was also loudly protesting any use of medications. As a medical student, I had encountered patients who were agitated, but this moment felt vastly different because I was now tasked with addressing the problem. I still remember how my muscles tensed out of anxiety. As the attending took the lead in talking with the patient, the situation continued to escalate. The patient’s agitation was preventing them from being able to safely cooperate with staff despite our efforts at verbal de-escalation. As several staff members stayed with the patient, my attending and I went back to the workroom, where she instructed me to place orders for emergent medications. I sat there, an anxious intern with the solemn power and responsibility to order medications that might need to be administered against the will of an agitated patient. The moment was surreal.
A harsh reality
I had envisioned my first day of residency to be quite different. I had expected to sit with patients, healing them by listening to their stories and giving them the attention they deserved. But instead, I found myself nervously inputting medication orders, checking and rechecking that the doses and administration routes were accurate—all the while knowing that the patient would likely refuse the medications. If that occurred, the patient would need to be held by staff so the medications could be administered. Although I knew that administering emergent medications was the appropriate clinical decision to prevent harm to the patient and others, I felt conflicted by acting in opposition to the patient’s wishes. In that moment, intoxication or illness compromised patient autonomy for the sake of beneficence. I struggled with a creeping sense of guilt.
Although I did not have the chance to interact with this specific patient again, I often reflect on that encounter. I have learned that at times, the use of emergent medications or court commitments for medication administration or hospitalizations is necessary. Since that first shift, I have cared for many other patients who have received emergent medications under similar circumstances. I have observed that such treatment often stabilizes patients and enables me to engage them in meaningful conversation to optimize their care.
Lessons learned
While some of what I have experienced during my training has made me uncomfortable, I have taken with me several valuable lessons. When a patient’s intoxication or illness prevents shared decision-making, our focus as physicians should remain on the patient’s safety, health, and well-being. It is necessary to engage patients in conversations to enable us to understand what ails them and promptly determine the right treatment, tailored to their specific needs and goals.
Moving forward, I know that I will encounter many more similar situations. I hope to position myself quickly and safely alongside agitated patients to engage them in shared decision-making. As a physician, I will approach every encounter with my patients as an opportunity to understand their goals for care, and empower them to make informed decisions regarding their treatment.
Trainee-in-parenting in the time of COVID-19
My role as a mother expands and contracts in hard-won harmony with my role as a psychiatry resident. The magnitude of this responsibility compounded on itself when, seemingly overnight, the world we once trusted suddenly became unsafe. Coronavirus disease 2019 (COVID-19), deadly to immunocompromised individuals and the harbinger of a lethal autoimmune syndrome in children, was at our doorstep.
COVID-19 and parents who work in health care
After COVID-19 reached the United States, my fellow residents and I began to exchange nervous text messages, wondering what we could expect. Not only did the biological threat of the virus loom at the limited hospital entry points, but news alerts about infected front-line health care professionals and supply shortages jammed our cellphones. We quickly learned that some front-line physicians and nurses in New York had decided to live separately from their families. One article reported that a resident who was 5 months postpartum had chosen to live separately from her infant to protect her from exposure. “What a fundamental conflict of identity,” I thought as I read the article. Looking at my own young family, I felt our vulnerability overcome me. Would I have to do the same?
Difficult choices that exemplify both excitement and fear seem to define parenthood. Only months ago, I was selecting a car seat. As I scoured consumer reports, I became aware of a harrowing irony: in the excitement of nesting, I was also preparing for a collision. In March, when the quarantine began, I found myself evaluating my options for how to protect my family during a pandemic that often feels like a car crash in slow motion.
Health care professionals began to separate from their families to reduce the risk of transmission. Whether children went to live with relatives or health care workers stopped snuggling their young children, a structural boundary was formed just as the roots of attachment were taking shape. When asked about the loss inherent in this separation, these young parents expressed sadness but also said the choice was clear: their need to protect their families was absolute.
Meanwhile, some residents found themselves in a crash course on telemedicine. Safe from coronavirus exposure at work and liberated from a daily commute, these parents saw their young children more than ever before. Young children saw their parents who were residents more than ever before. Perhaps the isolation of a front-line resident was sadly not a new experience.
Reassessing priorities
Now that the first wave of infections has broken over our coastal cities, residents from the front lines of COVID-19 are reuniting with their families. The sacrifices they made are re-evaluated as they begin to recognize anew the value of physical closeness with their loved ones in a dangerous world. One family that separated during the first wave said they would plan an alternate strategy, perhaps invest in a babysitter, rather than divide the household a second time.
While COVID-19 hit us hard, it has also forced a rare opportunity for self-assessment of priorities that we as trainees rarely take. We don’t have a consumer report on the safety ratings of COVID-19 plans. There is no formula for success. Instead, we each balance work and personal life with individual strategies to cope with elements outside of our control. This coping strategy may look different for each family. I hope all training departments take this plurality into account when considering the new demands on residents that have emerged during COVID-19.
My role as a mother expands and contracts in hard-won harmony with my role as a psychiatry resident. The magnitude of this responsibility compounded on itself when, seemingly overnight, the world we once trusted suddenly became unsafe. Coronavirus disease 2019 (COVID-19), deadly to immunocompromised individuals and the harbinger of a lethal autoimmune syndrome in children, was at our doorstep.
COVID-19 and parents who work in health care
After COVID-19 reached the United States, my fellow residents and I began to exchange nervous text messages, wondering what we could expect. Not only did the biological threat of the virus loom at the limited hospital entry points, but news alerts about infected front-line health care professionals and supply shortages jammed our cellphones. We quickly learned that some front-line physicians and nurses in New York had decided to live separately from their families. One article reported that a resident who was 5 months postpartum had chosen to live separately from her infant to protect her from exposure. “What a fundamental conflict of identity,” I thought as I read the article. Looking at my own young family, I felt our vulnerability overcome me. Would I have to do the same?
Difficult choices that exemplify both excitement and fear seem to define parenthood. Only months ago, I was selecting a car seat. As I scoured consumer reports, I became aware of a harrowing irony: in the excitement of nesting, I was also preparing for a collision. In March, when the quarantine began, I found myself evaluating my options for how to protect my family during a pandemic that often feels like a car crash in slow motion.
Health care professionals began to separate from their families to reduce the risk of transmission. Whether children went to live with relatives or health care workers stopped snuggling their young children, a structural boundary was formed just as the roots of attachment were taking shape. When asked about the loss inherent in this separation, these young parents expressed sadness but also said the choice was clear: their need to protect their families was absolute.
Meanwhile, some residents found themselves in a crash course on telemedicine. Safe from coronavirus exposure at work and liberated from a daily commute, these parents saw their young children more than ever before. Young children saw their parents who were residents more than ever before. Perhaps the isolation of a front-line resident was sadly not a new experience.
Reassessing priorities
Now that the first wave of infections has broken over our coastal cities, residents from the front lines of COVID-19 are reuniting with their families. The sacrifices they made are re-evaluated as they begin to recognize anew the value of physical closeness with their loved ones in a dangerous world. One family that separated during the first wave said they would plan an alternate strategy, perhaps invest in a babysitter, rather than divide the household a second time.
While COVID-19 hit us hard, it has also forced a rare opportunity for self-assessment of priorities that we as trainees rarely take. We don’t have a consumer report on the safety ratings of COVID-19 plans. There is no formula for success. Instead, we each balance work and personal life with individual strategies to cope with elements outside of our control. This coping strategy may look different for each family. I hope all training departments take this plurality into account when considering the new demands on residents that have emerged during COVID-19.
My role as a mother expands and contracts in hard-won harmony with my role as a psychiatry resident. The magnitude of this responsibility compounded on itself when, seemingly overnight, the world we once trusted suddenly became unsafe. Coronavirus disease 2019 (COVID-19), deadly to immunocompromised individuals and the harbinger of a lethal autoimmune syndrome in children, was at our doorstep.
COVID-19 and parents who work in health care
After COVID-19 reached the United States, my fellow residents and I began to exchange nervous text messages, wondering what we could expect. Not only did the biological threat of the virus loom at the limited hospital entry points, but news alerts about infected front-line health care professionals and supply shortages jammed our cellphones. We quickly learned that some front-line physicians and nurses in New York had decided to live separately from their families. One article reported that a resident who was 5 months postpartum had chosen to live separately from her infant to protect her from exposure. “What a fundamental conflict of identity,” I thought as I read the article. Looking at my own young family, I felt our vulnerability overcome me. Would I have to do the same?
Difficult choices that exemplify both excitement and fear seem to define parenthood. Only months ago, I was selecting a car seat. As I scoured consumer reports, I became aware of a harrowing irony: in the excitement of nesting, I was also preparing for a collision. In March, when the quarantine began, I found myself evaluating my options for how to protect my family during a pandemic that often feels like a car crash in slow motion.
Health care professionals began to separate from their families to reduce the risk of transmission. Whether children went to live with relatives or health care workers stopped snuggling their young children, a structural boundary was formed just as the roots of attachment were taking shape. When asked about the loss inherent in this separation, these young parents expressed sadness but also said the choice was clear: their need to protect their families was absolute.
Meanwhile, some residents found themselves in a crash course on telemedicine. Safe from coronavirus exposure at work and liberated from a daily commute, these parents saw their young children more than ever before. Young children saw their parents who were residents more than ever before. Perhaps the isolation of a front-line resident was sadly not a new experience.
Reassessing priorities
Now that the first wave of infections has broken over our coastal cities, residents from the front lines of COVID-19 are reuniting with their families. The sacrifices they made are re-evaluated as they begin to recognize anew the value of physical closeness with their loved ones in a dangerous world. One family that separated during the first wave said they would plan an alternate strategy, perhaps invest in a babysitter, rather than divide the household a second time.
While COVID-19 hit us hard, it has also forced a rare opportunity for self-assessment of priorities that we as trainees rarely take. We don’t have a consumer report on the safety ratings of COVID-19 plans. There is no formula for success. Instead, we each balance work and personal life with individual strategies to cope with elements outside of our control. This coping strategy may look different for each family. I hope all training departments take this plurality into account when considering the new demands on residents that have emerged during COVID-19.
Treating patients during COVID-19: What I observed
I am a psychiatrist at a community mental health center located close to a large city. I want to report on our experience treating 100 consecutive, non-duplicative patients during the coronavirus disease 2019 (COVID-19) pandemic. Most of these patients had medical assistance or Medicare. Fifty-one were white, 46 were black, and 3 were Asian; 50 were men, and their ages ranged from 16 to 83 (mean: 54; median: 56). Using each patient as his/her own control (pre- and post–COVID-19), here I report 6 observations I made while treating these patients.
1. Telehealth worked for most patients. Of the 100 patients, 18 were seen in-person. Of the 18 seen in person, 14 received long-acting IM injections, and 2 patients presented with urgent matters that I felt required in-person evaluations. One patient needed to fill out several forms and provide consents, and 1 patient with chronic illness was treated at the clinic because he mistakenly arrived in person for his appointment.
The remaining 82 patients had telehealth sessions. Only 9 patients said they were able to use video conferencing, so the remaining 73 patients were treated by phone. These patients were mostly poor and/or older and had no access to smartphones or computers. This is especially important because the current emergency telehealth rules allow phone-only sessions, while regular telehealth rules do not. Our clinic strongly advocates for the extension of emergency telehealth rules. I have e-mailed many elected officials about this, but I have received few replies and no substantive responses. Our clinic also needs to help our patients obtain increased audiovisual capabilities.
2. Female patients fared better in their treatment than males.
3. Older patients did better than younger patients. Older patients’ experiences of living through past crises were helpful because they were able to compare how they persevered in the past with the current pandemic.
4. White patients showed more improvements compared with black patients. White patients generally had greater access to resources and support.
5. Patients with psychotic diagnoses/symptoms improved more than those with neurotic/anxiety/depressive diagnoses or symptoms. Most of our patients with psychotic diagnoses were already in a supportive, structured living environment, so the new “COVID-19 world” may be less disruptive for them. Additionally, it was more difficult for our patients to get substances of abuse because they had less mobility and access during the pandemic.
Continue to: Support
6. Support, especially from family but also institutional support, trumped other factors. The more support and structure our patients had, the better they did.
My observations may not be generalizable because I am reporting on a relatively small population size, most patients were older, and most were established patients who were likely more stable. I plan to follow up with these patients to see how the new COVID-19 world continues to affect them, and us.
Daniel D. Storch, MD
Key Point Health Services
Catonsville, Maryland
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
I am a psychiatrist at a community mental health center located close to a large city. I want to report on our experience treating 100 consecutive, non-duplicative patients during the coronavirus disease 2019 (COVID-19) pandemic. Most of these patients had medical assistance or Medicare. Fifty-one were white, 46 were black, and 3 were Asian; 50 were men, and their ages ranged from 16 to 83 (mean: 54; median: 56). Using each patient as his/her own control (pre- and post–COVID-19), here I report 6 observations I made while treating these patients.
1. Telehealth worked for most patients. Of the 100 patients, 18 were seen in-person. Of the 18 seen in person, 14 received long-acting IM injections, and 2 patients presented with urgent matters that I felt required in-person evaluations. One patient needed to fill out several forms and provide consents, and 1 patient with chronic illness was treated at the clinic because he mistakenly arrived in person for his appointment.
The remaining 82 patients had telehealth sessions. Only 9 patients said they were able to use video conferencing, so the remaining 73 patients were treated by phone. These patients were mostly poor and/or older and had no access to smartphones or computers. This is especially important because the current emergency telehealth rules allow phone-only sessions, while regular telehealth rules do not. Our clinic strongly advocates for the extension of emergency telehealth rules. I have e-mailed many elected officials about this, but I have received few replies and no substantive responses. Our clinic also needs to help our patients obtain increased audiovisual capabilities.
2. Female patients fared better in their treatment than males.
3. Older patients did better than younger patients. Older patients’ experiences of living through past crises were helpful because they were able to compare how they persevered in the past with the current pandemic.
4. White patients showed more improvements compared with black patients. White patients generally had greater access to resources and support.
5. Patients with psychotic diagnoses/symptoms improved more than those with neurotic/anxiety/depressive diagnoses or symptoms. Most of our patients with psychotic diagnoses were already in a supportive, structured living environment, so the new “COVID-19 world” may be less disruptive for them. Additionally, it was more difficult for our patients to get substances of abuse because they had less mobility and access during the pandemic.
Continue to: Support
6. Support, especially from family but also institutional support, trumped other factors. The more support and structure our patients had, the better they did.
My observations may not be generalizable because I am reporting on a relatively small population size, most patients were older, and most were established patients who were likely more stable. I plan to follow up with these patients to see how the new COVID-19 world continues to affect them, and us.
Daniel D. Storch, MD
Key Point Health Services
Catonsville, Maryland
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
I am a psychiatrist at a community mental health center located close to a large city. I want to report on our experience treating 100 consecutive, non-duplicative patients during the coronavirus disease 2019 (COVID-19) pandemic. Most of these patients had medical assistance or Medicare. Fifty-one were white, 46 were black, and 3 were Asian; 50 were men, and their ages ranged from 16 to 83 (mean: 54; median: 56). Using each patient as his/her own control (pre- and post–COVID-19), here I report 6 observations I made while treating these patients.
1. Telehealth worked for most patients. Of the 100 patients, 18 were seen in-person. Of the 18 seen in person, 14 received long-acting IM injections, and 2 patients presented with urgent matters that I felt required in-person evaluations. One patient needed to fill out several forms and provide consents, and 1 patient with chronic illness was treated at the clinic because he mistakenly arrived in person for his appointment.
The remaining 82 patients had telehealth sessions. Only 9 patients said they were able to use video conferencing, so the remaining 73 patients were treated by phone. These patients were mostly poor and/or older and had no access to smartphones or computers. This is especially important because the current emergency telehealth rules allow phone-only sessions, while regular telehealth rules do not. Our clinic strongly advocates for the extension of emergency telehealth rules. I have e-mailed many elected officials about this, but I have received few replies and no substantive responses. Our clinic also needs to help our patients obtain increased audiovisual capabilities.
2. Female patients fared better in their treatment than males.
3. Older patients did better than younger patients. Older patients’ experiences of living through past crises were helpful because they were able to compare how they persevered in the past with the current pandemic.
4. White patients showed more improvements compared with black patients. White patients generally had greater access to resources and support.
5. Patients with psychotic diagnoses/symptoms improved more than those with neurotic/anxiety/depressive diagnoses or symptoms. Most of our patients with psychotic diagnoses were already in a supportive, structured living environment, so the new “COVID-19 world” may be less disruptive for them. Additionally, it was more difficult for our patients to get substances of abuse because they had less mobility and access during the pandemic.
Continue to: Support
6. Support, especially from family but also institutional support, trumped other factors. The more support and structure our patients had, the better they did.
My observations may not be generalizable because I am reporting on a relatively small population size, most patients were older, and most were established patients who were likely more stable. I plan to follow up with these patients to see how the new COVID-19 world continues to affect them, and us.
Daniel D. Storch, MD
Key Point Health Services
Catonsville, Maryland
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Neuro-politics: Will you vote with your cortex or limbic system?
It’s election season again. Every 4 years, October becomes the purgatory month of politics. But this year, it’s even more complicated, being juxtaposed against a chaotic mosaic of a viral pandemic, economic travails, social upheaval, and exceptionally toxic political hyperpartisanship.
The widespread expectation is that citizens will vote for their party’s candidates, but there is now a body of evidence suggesting that our brains may be pre-wired to be liberal or conservative.
Enter neuro-politics. This discipline is younger than neuro-economics, neuro-law, neuro-ethics, neuro-marketing, neuro-art, neuro-culture, or neuro-esthetics. Neuro-politics focuses on the intersection of politics with neuroscience.1 However, there are many antecedents to neuro-politics reflected in the writings of Plato, Aristotle, Niccolò Machiavelli, John Locke, Baruch Spinoza, Henri Bergson, William James, and others.
Neuro-politics attempts to generate data to answer a variety of questions about political behavior, such as:
- Is political orientation associated with differences in certain brain regions?
- Are there reliable neural biomarkers of political orientation?
- Is political orientation modifiable, and if so, why are some individuals ferociously entrenched to one political dogma while others are able to untether themselves and adopt another political doctrine?
- What are the brain characteristics of “swing voters” who may align themselves with different parties in different election cycles?
- Is there a “religification” of politics among the ardent fanatics who regard the tenets of their political beliefs as “articles of faith?”
- Is the brain modified by certain attributes (such as educational level, age, sex, marital status, race, ethnicity, and religious affiliation) that translate to political decision-making?
- Can neuro-politics explain the sprouting of psychiatric symptoms such as obsessions, anxiety, irritability, anger, hatred, and conspiracy theories?
- Is political extremism driven by cortical structures, limbic structures, or both?
Politics and the brain
Here is a brief review of some studies that examined the relationship of political orientation or voting behavior with brain structure and function:
1. Roger Sperry, the 1981 Nobel Laureate (for his studies on split-brain patients) reported that in patients who underwent callosotomy, both cerebral hemispheres gave the same ratings of politicians when their photos were shown to each hemisphere separately.2
2. A functional magnetic resonance imaging (fMRI) study found that the faces of candidates activated participants’ ventromedial and anterior prefrontal cortices. Amygdala activation was associated with the intensity of the emotion.3
Continue to: A skin conductance...
3. A skin conductance study reported that politically liberal individuals had low reactivity to sudden noises and threatening stimuli, while conservative counterparts demonstrated high physiological reactions to noises and stimuli.4
4. Images of a losing candidate elicited greater activation on fMRI in the insula and ventral anterior cingulate compared to no activation by exposure to an image of the winning candidate.5
5. Another fMRI study found that “individualism” was associated with activation of the medial prefrontal cortex and temporo-parietal junction when participants listened to a set of political statements. On the other hand, “conservatism” activated the dorsolateral prefrontal cortex, while “radicalism” activated the ventral striatum and posterior cingulate.6
6. An EEG activity study of healthy individuals revealed desynchronization in the alpha band related to the politicians who lost simulated elections and were judged as “less trustworthy” when the participant watched their faces.7
7. A structural MRI study of young adults reported that liberalism was associated with increased gray matter volume in the anterior cingulate, while conservatism was associated with increased volume of the right amygdala. The authors replicated their findings and concluded there is a possible link between brain structure and psychological mechanisms that mediate political attitudes.8
Continue to: To examine the effect of...
8. To examine the effect of a “first impression” based on the physical appearance of candidates, researchers compared individuals with damage to the lateral orbitofrontal cortex (OFC) with a group that had frontal damage that spared the lateral OFC and another group of matched healthy volunteers. They used a simulated elections paradigm in which participants voted based solely on photographs of the candidates’ faces. Only the group with OFC damage was influenced by attractiveness, while those with an intact frontal lobe or non-OFC frontal damage relied on other data, such as competence.9 These researchers concluded that an intact OFC is necessary for political decision-making.
9. A study using cognitive tasks reported that liberals are more adept at dealing with novel information than conservatives.10
What part of your brain will you use?
Regardless of the data generated by the neuro-politics studies, the bottom line is: What part of your brain do you use when you cast your vote for an issue, a representative, a senator, or a president? Is it a purely intellectual decision (ie, cortical), or is it driven by visceral emotions (ie, limbic)? Do you believe that every single item in your party’s platform is right and virtuous, while every item in the other party’s platform is wrong and evil? Can you think of any redeeming feature of the candidate you hate or the party you despise?
One attribute that we psychiatrists possess by virtue of our training and clinical work is that we are able to transcend dichotomies and to perceive nuances and shades of gray about controversial issues. So I hope we employ the circuits of our brain where wisdom putatively resides11 and which may develop further (via neuroplasticity) with the conduct of psychotherapy.12 Those brain circuits include:
- prefrontal cortex (for emotional regulation, decision-making, and value relativism)
- lateral prefrontal cortex (to facilitate calculated, reason-based decision-making)
- medial prefrontal cortex (for emotional valence and pro-social attitudes and behaviors).
However, being human, it is quite likely that our amygdala may “seep through” and color our judgment and decisions. But let us try to cast a vote that is not only good for the country but also good for our patients, many of whom may not even be able to vote. Election season is a time to make a positive difference in our patients’ lives, not just ours. Let’s hope our brains exploit this unique opportunity.
1. Schreiber D. Neuropolitics: twenty years later. Politics Life Sci. 2017;36(2):114-131.
2. Sperry RW, Zaidel E, Zaidel D. Self recognition and social awareness in the deconnected minor hemisphere. Neuropsychologia. 1979;17(2):153-166.
3. Knutson KM, Wood JN, Spampinato MV, et al. Politics on the brain: an FMRI investigation. Soc Neurosci. 2006;1(1):25-40.
4. Oxley DR, Smith KB, Alford JR, et al. Political attitudes vary with physiological traits. Science. 2008;321(5896):1667-1670.
5. Spezio ML, Rangel A, Alvarez RM, et al. A neural basis for the effect of candidate appearance on election outcomes. Soc Cogn Affect Neurosci. 2008;3(4):344-352.
6. Zamboni G, Gozzi M, Krueger F, et al. Individualism, conservatism, and radicalism as criteria for processing political beliefs: a parametric fMRI study. Soc Neurosci. 2009;4(5):367-383.
7. Vecchiato G, Toppi J, Cincotti F, et al. Neuropolitics: EEG spectral maps related to a political vote based on the first impression of the candidate’s face. Conf Proc IEEE Eng Med Biol Soc. 2010;2010:2902-2905.
8. Kanai R, Feilden T, Firth C, et al. Political orientations are correlated with brain structure in young adults. Curr Biol. 2011;21(8):677-680.
9. Xia C, Stolle D, Gidengil E, et al. Lateral orbitofrontal cortex links social impressions to political choices. J Neurosci. 2015;35(22):8507-8514.
10. Bernabel RT, Oliveira A. Conservatism and liberalism predict performance in two nonideological cognitive tasks. Politics Life Sci. 2017;36(2):49-59.
11. Meeks TW, Jeste DV. Neurobiology of wisdom: a literature overview. Arch Gen Psychiatry. 2009;66(4):355-365.
12. Nasrallah HA. Does psychiatric practice make us wiser? Current Psychiatry. 2009;8(10):12,14.
It’s election season again. Every 4 years, October becomes the purgatory month of politics. But this year, it’s even more complicated, being juxtaposed against a chaotic mosaic of a viral pandemic, economic travails, social upheaval, and exceptionally toxic political hyperpartisanship.
The widespread expectation is that citizens will vote for their party’s candidates, but there is now a body of evidence suggesting that our brains may be pre-wired to be liberal or conservative.
Enter neuro-politics. This discipline is younger than neuro-economics, neuro-law, neuro-ethics, neuro-marketing, neuro-art, neuro-culture, or neuro-esthetics. Neuro-politics focuses on the intersection of politics with neuroscience.1 However, there are many antecedents to neuro-politics reflected in the writings of Plato, Aristotle, Niccolò Machiavelli, John Locke, Baruch Spinoza, Henri Bergson, William James, and others.
Neuro-politics attempts to generate data to answer a variety of questions about political behavior, such as:
- Is political orientation associated with differences in certain brain regions?
- Are there reliable neural biomarkers of political orientation?
- Is political orientation modifiable, and if so, why are some individuals ferociously entrenched to one political dogma while others are able to untether themselves and adopt another political doctrine?
- What are the brain characteristics of “swing voters” who may align themselves with different parties in different election cycles?
- Is there a “religification” of politics among the ardent fanatics who regard the tenets of their political beliefs as “articles of faith?”
- Is the brain modified by certain attributes (such as educational level, age, sex, marital status, race, ethnicity, and religious affiliation) that translate to political decision-making?
- Can neuro-politics explain the sprouting of psychiatric symptoms such as obsessions, anxiety, irritability, anger, hatred, and conspiracy theories?
- Is political extremism driven by cortical structures, limbic structures, or both?
Politics and the brain
Here is a brief review of some studies that examined the relationship of political orientation or voting behavior with brain structure and function:
1. Roger Sperry, the 1981 Nobel Laureate (for his studies on split-brain patients) reported that in patients who underwent callosotomy, both cerebral hemispheres gave the same ratings of politicians when their photos were shown to each hemisphere separately.2
2. A functional magnetic resonance imaging (fMRI) study found that the faces of candidates activated participants’ ventromedial and anterior prefrontal cortices. Amygdala activation was associated with the intensity of the emotion.3
Continue to: A skin conductance...
3. A skin conductance study reported that politically liberal individuals had low reactivity to sudden noises and threatening stimuli, while conservative counterparts demonstrated high physiological reactions to noises and stimuli.4
4. Images of a losing candidate elicited greater activation on fMRI in the insula and ventral anterior cingulate compared to no activation by exposure to an image of the winning candidate.5
5. Another fMRI study found that “individualism” was associated with activation of the medial prefrontal cortex and temporo-parietal junction when participants listened to a set of political statements. On the other hand, “conservatism” activated the dorsolateral prefrontal cortex, while “radicalism” activated the ventral striatum and posterior cingulate.6
6. An EEG activity study of healthy individuals revealed desynchronization in the alpha band related to the politicians who lost simulated elections and were judged as “less trustworthy” when the participant watched their faces.7
7. A structural MRI study of young adults reported that liberalism was associated with increased gray matter volume in the anterior cingulate, while conservatism was associated with increased volume of the right amygdala. The authors replicated their findings and concluded there is a possible link between brain structure and psychological mechanisms that mediate political attitudes.8
Continue to: To examine the effect of...
8. To examine the effect of a “first impression” based on the physical appearance of candidates, researchers compared individuals with damage to the lateral orbitofrontal cortex (OFC) with a group that had frontal damage that spared the lateral OFC and another group of matched healthy volunteers. They used a simulated elections paradigm in which participants voted based solely on photographs of the candidates’ faces. Only the group with OFC damage was influenced by attractiveness, while those with an intact frontal lobe or non-OFC frontal damage relied on other data, such as competence.9 These researchers concluded that an intact OFC is necessary for political decision-making.
9. A study using cognitive tasks reported that liberals are more adept at dealing with novel information than conservatives.10
What part of your brain will you use?
Regardless of the data generated by the neuro-politics studies, the bottom line is: What part of your brain do you use when you cast your vote for an issue, a representative, a senator, or a president? Is it a purely intellectual decision (ie, cortical), or is it driven by visceral emotions (ie, limbic)? Do you believe that every single item in your party’s platform is right and virtuous, while every item in the other party’s platform is wrong and evil? Can you think of any redeeming feature of the candidate you hate or the party you despise?
One attribute that we psychiatrists possess by virtue of our training and clinical work is that we are able to transcend dichotomies and to perceive nuances and shades of gray about controversial issues. So I hope we employ the circuits of our brain where wisdom putatively resides11 and which may develop further (via neuroplasticity) with the conduct of psychotherapy.12 Those brain circuits include:
- prefrontal cortex (for emotional regulation, decision-making, and value relativism)
- lateral prefrontal cortex (to facilitate calculated, reason-based decision-making)
- medial prefrontal cortex (for emotional valence and pro-social attitudes and behaviors).
However, being human, it is quite likely that our amygdala may “seep through” and color our judgment and decisions. But let us try to cast a vote that is not only good for the country but also good for our patients, many of whom may not even be able to vote. Election season is a time to make a positive difference in our patients’ lives, not just ours. Let’s hope our brains exploit this unique opportunity.
It’s election season again. Every 4 years, October becomes the purgatory month of politics. But this year, it’s even more complicated, being juxtaposed against a chaotic mosaic of a viral pandemic, economic travails, social upheaval, and exceptionally toxic political hyperpartisanship.
The widespread expectation is that citizens will vote for their party’s candidates, but there is now a body of evidence suggesting that our brains may be pre-wired to be liberal or conservative.
Enter neuro-politics. This discipline is younger than neuro-economics, neuro-law, neuro-ethics, neuro-marketing, neuro-art, neuro-culture, or neuro-esthetics. Neuro-politics focuses on the intersection of politics with neuroscience.1 However, there are many antecedents to neuro-politics reflected in the writings of Plato, Aristotle, Niccolò Machiavelli, John Locke, Baruch Spinoza, Henri Bergson, William James, and others.
Neuro-politics attempts to generate data to answer a variety of questions about political behavior, such as:
- Is political orientation associated with differences in certain brain regions?
- Are there reliable neural biomarkers of political orientation?
- Is political orientation modifiable, and if so, why are some individuals ferociously entrenched to one political dogma while others are able to untether themselves and adopt another political doctrine?
- What are the brain characteristics of “swing voters” who may align themselves with different parties in different election cycles?
- Is there a “religification” of politics among the ardent fanatics who regard the tenets of their political beliefs as “articles of faith?”
- Is the brain modified by certain attributes (such as educational level, age, sex, marital status, race, ethnicity, and religious affiliation) that translate to political decision-making?
- Can neuro-politics explain the sprouting of psychiatric symptoms such as obsessions, anxiety, irritability, anger, hatred, and conspiracy theories?
- Is political extremism driven by cortical structures, limbic structures, or both?
Politics and the brain
Here is a brief review of some studies that examined the relationship of political orientation or voting behavior with brain structure and function:
1. Roger Sperry, the 1981 Nobel Laureate (for his studies on split-brain patients) reported that in patients who underwent callosotomy, both cerebral hemispheres gave the same ratings of politicians when their photos were shown to each hemisphere separately.2
2. A functional magnetic resonance imaging (fMRI) study found that the faces of candidates activated participants’ ventromedial and anterior prefrontal cortices. Amygdala activation was associated with the intensity of the emotion.3
Continue to: A skin conductance...
3. A skin conductance study reported that politically liberal individuals had low reactivity to sudden noises and threatening stimuli, while conservative counterparts demonstrated high physiological reactions to noises and stimuli.4
4. Images of a losing candidate elicited greater activation on fMRI in the insula and ventral anterior cingulate compared to no activation by exposure to an image of the winning candidate.5
5. Another fMRI study found that “individualism” was associated with activation of the medial prefrontal cortex and temporo-parietal junction when participants listened to a set of political statements. On the other hand, “conservatism” activated the dorsolateral prefrontal cortex, while “radicalism” activated the ventral striatum and posterior cingulate.6
6. An EEG activity study of healthy individuals revealed desynchronization in the alpha band related to the politicians who lost simulated elections and were judged as “less trustworthy” when the participant watched their faces.7
7. A structural MRI study of young adults reported that liberalism was associated with increased gray matter volume in the anterior cingulate, while conservatism was associated with increased volume of the right amygdala. The authors replicated their findings and concluded there is a possible link between brain structure and psychological mechanisms that mediate political attitudes.8
Continue to: To examine the effect of...
8. To examine the effect of a “first impression” based on the physical appearance of candidates, researchers compared individuals with damage to the lateral orbitofrontal cortex (OFC) with a group that had frontal damage that spared the lateral OFC and another group of matched healthy volunteers. They used a simulated elections paradigm in which participants voted based solely on photographs of the candidates’ faces. Only the group with OFC damage was influenced by attractiveness, while those with an intact frontal lobe or non-OFC frontal damage relied on other data, such as competence.9 These researchers concluded that an intact OFC is necessary for political decision-making.
9. A study using cognitive tasks reported that liberals are more adept at dealing with novel information than conservatives.10
What part of your brain will you use?
Regardless of the data generated by the neuro-politics studies, the bottom line is: What part of your brain do you use when you cast your vote for an issue, a representative, a senator, or a president? Is it a purely intellectual decision (ie, cortical), or is it driven by visceral emotions (ie, limbic)? Do you believe that every single item in your party’s platform is right and virtuous, while every item in the other party’s platform is wrong and evil? Can you think of any redeeming feature of the candidate you hate or the party you despise?
One attribute that we psychiatrists possess by virtue of our training and clinical work is that we are able to transcend dichotomies and to perceive nuances and shades of gray about controversial issues. So I hope we employ the circuits of our brain where wisdom putatively resides11 and which may develop further (via neuroplasticity) with the conduct of psychotherapy.12 Those brain circuits include:
- prefrontal cortex (for emotional regulation, decision-making, and value relativism)
- lateral prefrontal cortex (to facilitate calculated, reason-based decision-making)
- medial prefrontal cortex (for emotional valence and pro-social attitudes and behaviors).
However, being human, it is quite likely that our amygdala may “seep through” and color our judgment and decisions. But let us try to cast a vote that is not only good for the country but also good for our patients, many of whom may not even be able to vote. Election season is a time to make a positive difference in our patients’ lives, not just ours. Let’s hope our brains exploit this unique opportunity.
1. Schreiber D. Neuropolitics: twenty years later. Politics Life Sci. 2017;36(2):114-131.
2. Sperry RW, Zaidel E, Zaidel D. Self recognition and social awareness in the deconnected minor hemisphere. Neuropsychologia. 1979;17(2):153-166.
3. Knutson KM, Wood JN, Spampinato MV, et al. Politics on the brain: an FMRI investigation. Soc Neurosci. 2006;1(1):25-40.
4. Oxley DR, Smith KB, Alford JR, et al. Political attitudes vary with physiological traits. Science. 2008;321(5896):1667-1670.
5. Spezio ML, Rangel A, Alvarez RM, et al. A neural basis for the effect of candidate appearance on election outcomes. Soc Cogn Affect Neurosci. 2008;3(4):344-352.
6. Zamboni G, Gozzi M, Krueger F, et al. Individualism, conservatism, and radicalism as criteria for processing political beliefs: a parametric fMRI study. Soc Neurosci. 2009;4(5):367-383.
7. Vecchiato G, Toppi J, Cincotti F, et al. Neuropolitics: EEG spectral maps related to a political vote based on the first impression of the candidate’s face. Conf Proc IEEE Eng Med Biol Soc. 2010;2010:2902-2905.
8. Kanai R, Feilden T, Firth C, et al. Political orientations are correlated with brain structure in young adults. Curr Biol. 2011;21(8):677-680.
9. Xia C, Stolle D, Gidengil E, et al. Lateral orbitofrontal cortex links social impressions to political choices. J Neurosci. 2015;35(22):8507-8514.
10. Bernabel RT, Oliveira A. Conservatism and liberalism predict performance in two nonideological cognitive tasks. Politics Life Sci. 2017;36(2):49-59.
11. Meeks TW, Jeste DV. Neurobiology of wisdom: a literature overview. Arch Gen Psychiatry. 2009;66(4):355-365.
12. Nasrallah HA. Does psychiatric practice make us wiser? Current Psychiatry. 2009;8(10):12,14.
1. Schreiber D. Neuropolitics: twenty years later. Politics Life Sci. 2017;36(2):114-131.
2. Sperry RW, Zaidel E, Zaidel D. Self recognition and social awareness in the deconnected minor hemisphere. Neuropsychologia. 1979;17(2):153-166.
3. Knutson KM, Wood JN, Spampinato MV, et al. Politics on the brain: an FMRI investigation. Soc Neurosci. 2006;1(1):25-40.
4. Oxley DR, Smith KB, Alford JR, et al. Political attitudes vary with physiological traits. Science. 2008;321(5896):1667-1670.
5. Spezio ML, Rangel A, Alvarez RM, et al. A neural basis for the effect of candidate appearance on election outcomes. Soc Cogn Affect Neurosci. 2008;3(4):344-352.
6. Zamboni G, Gozzi M, Krueger F, et al. Individualism, conservatism, and radicalism as criteria for processing political beliefs: a parametric fMRI study. Soc Neurosci. 2009;4(5):367-383.
7. Vecchiato G, Toppi J, Cincotti F, et al. Neuropolitics: EEG spectral maps related to a political vote based on the first impression of the candidate’s face. Conf Proc IEEE Eng Med Biol Soc. 2010;2010:2902-2905.
8. Kanai R, Feilden T, Firth C, et al. Political orientations are correlated with brain structure in young adults. Curr Biol. 2011;21(8):677-680.
9. Xia C, Stolle D, Gidengil E, et al. Lateral orbitofrontal cortex links social impressions to political choices. J Neurosci. 2015;35(22):8507-8514.
10. Bernabel RT, Oliveira A. Conservatism and liberalism predict performance in two nonideological cognitive tasks. Politics Life Sci. 2017;36(2):49-59.
11. Meeks TW, Jeste DV. Neurobiology of wisdom: a literature overview. Arch Gen Psychiatry. 2009;66(4):355-365.
12. Nasrallah HA. Does psychiatric practice make us wiser? Current Psychiatry. 2009;8(10):12,14.
Despite overall exhaustion, health care workers continue on
I write this editorial in mid-September. Fires (and ash) are devastating the West and multiple hurricanes are pummeling the Gulf Coast states. We are struggling to admit how our democracy has systematically failed so many people and learn how we might rectify past inequities and abuses so we can create a better future together. All this with the backdrop of COVID-19, as we pass 200,000 American deaths. We will figure this out and be stronger, but for now it is exhausting, and many people are suffering.
The year 2020 will change gastroenterology forever. The economic fallout already has accelerated the disappearance of traditional medical practices, whose finances were based on steady cash flow. Medicaid rolls will increase from 70 million to over 80 million next year, putting State budgets in deficit and likely altering enrollment requirements. Currently, only half of Baby Boomers are enrolled in Medicare, a statistic that will change with loss of employment and early retirements. Many Americans are losing their employer-based insurance and shifting to government-based insurance (or losing insurance entirely). Providers will face enormous financial headwinds for years no matter how rapidly our economy recovers.
But not all news is bad. We can still read how scientific knowledge continues to progress (our issue this month is rich with examples). Our responses to COVID-19 have been breath-taking in their speed. The death rate per hospitalized patient has fallen dramatically, we continue to learn how to mitigate the effects of COVID-19, and we anticipate a vaccine in record time compared with past epidemics. Physicians and other health care providers are demonstrating daily their dedication to patients despite physical, emotional, and mental exhaustion.
I have no glib answers or words of advice. But I continue to be optimistic. In a nonpartisan tone, I quote Bill Clinton’s 1993 inaugural address: “There is nothing wrong with America that cannot be cured by what is right with America.”
John I. Allen, MD, MBA, AGAF
Editor in Chief
I write this editorial in mid-September. Fires (and ash) are devastating the West and multiple hurricanes are pummeling the Gulf Coast states. We are struggling to admit how our democracy has systematically failed so many people and learn how we might rectify past inequities and abuses so we can create a better future together. All this with the backdrop of COVID-19, as we pass 200,000 American deaths. We will figure this out and be stronger, but for now it is exhausting, and many people are suffering.
The year 2020 will change gastroenterology forever. The economic fallout already has accelerated the disappearance of traditional medical practices, whose finances were based on steady cash flow. Medicaid rolls will increase from 70 million to over 80 million next year, putting State budgets in deficit and likely altering enrollment requirements. Currently, only half of Baby Boomers are enrolled in Medicare, a statistic that will change with loss of employment and early retirements. Many Americans are losing their employer-based insurance and shifting to government-based insurance (or losing insurance entirely). Providers will face enormous financial headwinds for years no matter how rapidly our economy recovers.
But not all news is bad. We can still read how scientific knowledge continues to progress (our issue this month is rich with examples). Our responses to COVID-19 have been breath-taking in their speed. The death rate per hospitalized patient has fallen dramatically, we continue to learn how to mitigate the effects of COVID-19, and we anticipate a vaccine in record time compared with past epidemics. Physicians and other health care providers are demonstrating daily their dedication to patients despite physical, emotional, and mental exhaustion.
I have no glib answers or words of advice. But I continue to be optimistic. In a nonpartisan tone, I quote Bill Clinton’s 1993 inaugural address: “There is nothing wrong with America that cannot be cured by what is right with America.”
John I. Allen, MD, MBA, AGAF
Editor in Chief
I write this editorial in mid-September. Fires (and ash) are devastating the West and multiple hurricanes are pummeling the Gulf Coast states. We are struggling to admit how our democracy has systematically failed so many people and learn how we might rectify past inequities and abuses so we can create a better future together. All this with the backdrop of COVID-19, as we pass 200,000 American deaths. We will figure this out and be stronger, but for now it is exhausting, and many people are suffering.
The year 2020 will change gastroenterology forever. The economic fallout already has accelerated the disappearance of traditional medical practices, whose finances were based on steady cash flow. Medicaid rolls will increase from 70 million to over 80 million next year, putting State budgets in deficit and likely altering enrollment requirements. Currently, only half of Baby Boomers are enrolled in Medicare, a statistic that will change with loss of employment and early retirements. Many Americans are losing their employer-based insurance and shifting to government-based insurance (or losing insurance entirely). Providers will face enormous financial headwinds for years no matter how rapidly our economy recovers.
But not all news is bad. We can still read how scientific knowledge continues to progress (our issue this month is rich with examples). Our responses to COVID-19 have been breath-taking in their speed. The death rate per hospitalized patient has fallen dramatically, we continue to learn how to mitigate the effects of COVID-19, and we anticipate a vaccine in record time compared with past epidemics. Physicians and other health care providers are demonstrating daily their dedication to patients despite physical, emotional, and mental exhaustion.
I have no glib answers or words of advice. But I continue to be optimistic. In a nonpartisan tone, I quote Bill Clinton’s 1993 inaugural address: “There is nothing wrong with America that cannot be cured by what is right with America.”
John I. Allen, MD, MBA, AGAF
Editor in Chief