Newly Diagnosed Cancer? Here is Your "What to Expect" Book

October is Breast Cancer Awareness month, but every month is the right time for preventative medicine (schedule that physical and mammogram!) For me, this is a milestone year, with daily Facebook reminders that my high school classmates are turning the big 5-0. As we start this wonderful "second half"of the game of life, more and more of us are facing the challenge of a cancer diagnosis.

As a family doctor, I have too often seen the deer-in-the-headlights look on my patient's face as I shared the difficult news of a cancer diagnosis. Each time, I feel like time stops for a few moments, and like a cartoon character babbling on, my words are collecting out there in a balloon while the word CANCER echoes back and forth in my patient's reality. I have had countless friends, colleagues and relatives face this challenge as well, and in every situation, my heart aches to help them as my medical brain searches for answers. I am a family physician, so while I am well versed at diagnosing a variety of cancers, I have limited hands-on experience in treatment.

Julie Silver, MD, is a Harvard doctor who specializes in rehabilitation medicine. She faced the diagnosis of breast cancer herself at only thirty-six, right in the middle of being a busy mom, wife and full time physician and medical author. As such, she is uniquely qualified to author "Before and After Cancer Treatment: Heal Faster, Better, Stronger" and the second edition has recently been released by Johns Hopkins University Press. From my perspective, Dr. Silver's book is the perfect blend of scientific analysis of cancer treatment and practical advice on "what to expect when you have cancer." My generation loved our "what to expect" books for pregnancy and toddler years, and now we have a book that meets that practical function when the cancer bomb explodes into our lives.

Dr. Silver addresses alternative medicine, meditation, exercise, spirituality, love, relationships and goal-setting. She advocates for patients to seek second opinions and be proactive about cancer PREhabilitiation to get "as strong as possible- physically and emotionally- BEFORE you begin treatment." She incorporates her personal experiences as well as those of many others, including excerpts from a book she published with the American Cancer Society called What Helped Get Me Through: Cancer Survivors Share Wisdom and Hope, as well as vignettes from other books and survivors.

Facing cancer often means many hours of down time, when the chemo-fatigue drains you of productive energy. Sleep is good. True rest is VERY good. Friends providing family meals and pitching in on the "invisible work" of groceries, laundry, and house maintenance is extremely helpful. Let your friend diagnosed with cancer conserve their energy for the things that matter the MOST- their family, their passions. Tuck this book in with the first meal that you provide.

BOTTOM LINE: If you (or your friend) is diagnosed with cancer, Dr. Silver's new book is a great resource to HEAL FASTER, BETTER, STRONGER. 

Mammograms, Breasts, and Exams...oh My!

Thinking PINK? October is Breast Cancer Awareness month, and pink ribbons are popping up on everything from restaurants and t-shirts to football socks. I love that as a community, we can rally around a cause to raise not only awareness, but also much needed funds for research and support of those affected.

The American Cancer Society statistics reveal that here in the United States, over 230,000 women will be diagnosed with breast cancer during 2015, and sadly, over 40,000 women will likely lose their lives to this disease. The good news is detection methods continue to improve, allowing these cancers to be diagnosed and treated earlier, leading to better outcomes and treatments that are better tolerated.

With all the changes in women's preventative health, many are confused about current recommendations for breast cancer, including health care providers. Different organizations have conflicting guidelines, which fuels the continued media controversy surrounding mammograms.

The United States Preventative Services Task Force (USPSTF) recommends routing SCREENING mammograms every other year for women ages 50-74. I emphasize "screening" because this guideline is for women with no symptoms, no concerning breast lumps and no extra risk factors. If a woman goes to the doctor with a concerning lump in her breast, imaging is most likely indicated- this is not "screening" in this situation, it is "diagnostic." The USPSTF also no longer promotes self-breast exams, because some large studies have not shown these exams to be globally beneficial. Statistically, self breast exams do not cut down on the number of deaths from cancer, and do lead to extra imaging studies (mammograms) and breast biopsies.

The American Cancer Society (ACS) still recommends annual mammograms for women forty and over, as long as they are in good health (not stopping at age 74 purely for too many birthdays, but rather only stopping if the woman has a shortened life expectancy from other serious medical issues.) ACS also still supports self breast exams for women starting in their twenties.

Given this information, do I still teach self breast exams? Right now, I am only seeing patients in an urgent care setting, so I do not have the opportunity to perform "well woman" exams. However, if I am seeing a patient with a breast-related issue that involves me doing a clinical breast exam, then YES, I do explain to patients what to expect when they perform a self-breast exam. I am not on the band wagon insisting patient MUST do these exams religiously on the first of every month (or after their period) as I used to suggest.

One of the greatest challenges in modern medicine is trying to practice evidence-based medicine that is recommended for the global good, versus a clinician's personal experience and success with individual patients. In this case, during my twenty years of private practice, I had numerous patients who found their own breast cancers during routine self-exams, and were quickly diagnosed, treated and cured- often with simple surgical lumpectomies without additional chemo therapies. Would they have been so fortunate if they had not noticed a lump and simply waited for routine screening? We don't know, but most of these women within my practice were younger than 50, so I believe many may have developed more advanced cancers. And so I am conflicted, and continue to follow evidence-based research and extended discussions about pros and cons of breast exams.

BOTTOM LINE: Talk with your doctor about your personal risk for developing breast cancer, and together discuss your prevention strategy- including frequency and timing of breast exams, imaging with mammography or other modalities, and possible genetic testing if breast cancers run in your family.

What about Aleve?

On my Tylenol vs Advil blog, I did not directly mention naproxen, better known by a trade name, Aleve. Do I have that in the first aid kit? Yes.

How is naproxen(Aleve) different than ibuprofen (Advil)?
Let's start with how they are the SAME. Both are classified as "NSAIDs", which means Non-Steroid Anti-Inflammatory Drug. So both naproxen and ibuprofen can be used to decrease swelling and inflammation, and both will lower elevated body temperatures (fevers). The product insert explains that naproxen is indicated for the relief of pain and fever, including headaches, toothaches, muscle and back aches, arthritis pains and menstrual cramps.  Naproxen lasts longer than ibuprofen, so you only need to take it twice per day (every 12 hours) rather than ibuprofen's recommended 6-8 hours.

A quick perusal of the current medical literature does not reveal any shocking data between ibuprofen and naproxen- both have similar effectiveness in pain relief and in side effect profiles. That being said, in my clinical practice I have traditionally used naproxen as my NSAID of choice for menstrual cramps, especially when there is heavy bleeding along with the cramps. Physicians often use prescription strength* doses of naproxen twice daily for the week before menses, then go to as needed use of naproxen the week of menses. This frequently decreases the amount of menstrual bleeding and improves the cramps associated with periods. Could this be done with ibuprofen too? Yes, but since this is scheduled usage, it's nice to use a medication that is only twice per day versus three times.

All NSAIDs can potentially irritate the stomach lining and/or your kidneys, and they may cause fluid retention (do they make your rings feel tight?) In my clinical experience, though not supported by any recent evidence-based studies that I can find, the shorter acting NSAID ibuprofen often helps more with acute pain (especially injuries) than the longer acting naproxen, but this is really a personal preference.

BOTTOM LINE: Add "Aleve" (naproxen) to your first aid kit, and consider this a first choice for menstrual cramps. Figure out for yourself which type of NSAID (ibuprofen vs naprosyn) seems to work best for your other aches and pains, and talk with your doctor to be sure which one is right for you.

Tylenol VS Advil

Next into the First Aid kit should be a pain reliever/fever reducer...should you put in Advil* (meaning any brand of Ibuprofen) or Tylenol*( suggesting any brand of acetaminophen)?
Drum roll please...and the answer is BOTH.

Tylenol and Advil are two very different products that work in different pathways within the body. Although the exact mechanism is not fully understood, Tylenol works in the central nervous system to block production of prostaglandins, a substance that plays a key role in pain and fever. Advil-type products (known collectively as Non Steroid Anti Inflammatory Drugs, NSAIDs) work in the peripheral as well as the central nervous system also blocking production of prostaglandins, which gives them the added benefit of reducing inflammation.

Therefore, tylenol works for pain and fever, but not swelling. NSAIDs work for pain, fever and swelling. So why would you use tylenol, if it does less? A couple reasons:

• NSAIDs can irritate the stomach lining, so in the case of gastritis, stomach ulcers or nausea, tylenol would be a better choice
• NSAIDs may slow down blood clotting (increasing risk of bleeding) so for surgical patients or patients on blood thinners, tylenol would be a better choice
• If there are kidney problems* (NSAIDs can potentially harm the kidneys, but not the liver, whereas tylenol can potentially harm the liver, but not the kidneys)

When are NSAIDs better?

• High fevers often respond better to NSAIDs
• Muscle aches/sprains or swollen joints
• If the liver is inflamed or damaged* 

But wait, there's more!

One lesser known medical trick is to use BOTH, together (when there is not a medical reason to avoid using either one). Yes, at the same time. No, not for routine aches or pains. Evidence-based studies such as this Cochrane review on post-op pain medications have shown that using a combination of acetaminophen and an NSAID such as ibuprofen provide superior pain relief to either used alone. I tend to use two OTC ibuprofen pills along with two OTC extra strength acetaminophen for severe aches and pains such as an intense headache, severe pain from an injury, or for a high fever. The idea is that this combination packs a therapeutic punch as strong as a narcotic like codeine, but without the mind-altering sedation. 

Lastly- name brand or generic? In my opinion, this is purely an individual "cosmetic" decision. The name brand preparations often have coatings that make them easier to swallow vs. the generic, but otherwise I feel the generics have equivalent effectiveness overall.

BOTTOM LINE: Know the advantages and disadvantages of OTC pain relievers such as Advil (ibuprofen) and Tylenol (acetaminophen), and consider a combination dose for more intense pains. Talk with your doctor about the best choice for you!

Antihistamines VS Decongestants

Many people are confused about when to use an antihistamine vs a decongestant, which is not surprising since these medications both treat allergy symptoms, and in fact, are frequently put together in combination products. Here is a quick breakdown:

Antihistamines work "anti" (against) histamine, which is a chemical released in the body during an allergic response. Histamine causes itchy eyes, tearing, itchy nose, sneezing, and post-nasal drainage that creates scratchy or sore throats, as well as occasionally causing total skin itching or hives. Antihistamines, therefore, help decrease sneezing, dry up dripping noses, eyes and throats, and reduce hives.

Antihistamines may cause drowsiness, especially the original over the counter antihistamine known as diphenhydramine (brand name Benadryl.) More recently developed antihistamine products such as brand name Allegra, Claritin & Zyrtec are considered "non-sedating", but may still cause drowsiness in some people. All antihistamines cause some dryness of the mouth and nose- that is part of the goal.

Decongestants simply constrict blood vessels, which in the nose reduces that feeling of stuffiness. Decongestants alone do not affect sneezing, itchiness or sore throats. Decongestants are stimulating, similar to caffeine. Therefore, decongestants may cause some shakiness or anxiety, increased heart rate or increased blood pressure, or insomnia.

Both antihistamines and decongestants come in oral liquids, pills, and nasal sprays. Nasal decongestants should only be used very short term, however, because after a couple days of use, the body creates rebound congestion that defeats the purpose of using the decongestant.

Which should you keep in your first aid kit?
1. Diphenhydramine (Benadryl)- this is a sedating antihistamine; great for occasional difficulty falling asleep or for immediate treatment of an allergic reaction to a sting, food or medication.

2. NONsedating antihistamine of choice: for daytime use-choose a generic or brand name medication such as Allegra, Claritin or Zyrtec for seasonal allergic symptoms of sneezing, itching, drippy eyes, nose or throat or for hives.

3. Decongestant: phenylephrine is a common simple decongestant (the little red pills, common brand name Sudafed). Use when you have a stuffy nose. Okay to use the decongestant sprays (such as Afrin) for less than three days only; provides immediate effect to reduce stuffy nose sensation.

BOTTOM LINE: Rather than combination products, choose an antihistamine or decongestant separately based upon your specific symptoms. 

College First Aid Kit

Happy Fall 2015! I disappeared for the summer, as I finished writing the second edition of my first book (Seductive Delusions), as well as a series of medical articles for Livestrong.org. Since all of my patients are current college students, I thought I would share a series of posts about common health issues for otherwise healthy young adults. Pictured above is my favorite personalized gift for graduating high school seniors- a first aid kit, complete with  my instructions for "when and how to use what" to feel better.

Let's start with one very basic item that is RARELY found in dorm rooms: a THERMOMETER!

Knowing whether or not you have a true FEVER (temperature >100.4*) is a very helpful piece of information, especially when you are calling in to a nurse hotline to get advice about your symptoms. 

Allergies, for example, frequently cause sore throat, headache, and drainage, but do not elevate your temperature to a true fever level, but rather typically cause a slightly elevated temperature to 99*. Viral infections often will cause a SUBnormal temperature of around 98* (especially after the first day), even though you feel "feverish" or chilled. 

Not everyone "lives" at 98.6*, by the way. Check your temperature randomly a few times on different days/weeks when you feel perfectly fine, so you know what is YOUR normal. This is partly why we check temperatures on everyone who comes in to the doctor's office, at every visit- even when you are not sick (but there for a sprained ankle, blood pressure medication, insomnia, whatever.)  

A few side notes: if you are using an oral thermometer, be sure to wait a half hour after eating, drinking (or, heaven-forbid, smoking), because these activities will falsely elevate or lower the temperature measured in your mouth. Ear thermometers measure about a half degree Fahrenheit higher than oral thermometers. Finally, body temperature fluctuates roughly 1*F throughout the day, so check your baseline temperatures at different times. The goal is to find out your average normal temperature. Obviously, if your usual temperature is 97. 4*, a temperature of 100* really is a FEVER for you. 

Which type of thermometer is the best? 

For a college student, I recommend an inexpensive digital thermometer...maybe two, because the batteries wear out. The more expensive ear and temporal thermometers require more precision and effort to be accurate (removing ear wax, for example). Digital oral thermometers across the board seem to be fairly reliable. Old fashioned glass thermometers are no longer recommended, because of the risk of breaking and then exposure to mercury.

BOTTOM LINE: A college student's first aid kit should start with a thermometer, and encourage your son or daughter to learn their baseline temperature, AND to check their temperature before they call their university's health services advice line. 

PS. Virtually every university now has a 24 advice line staffed by an actual, live human being- be sure your college student has that number programmed in to their smart phone!

My Teacher Gave Me an Ulcer!

"Does STRESS cause stomach ulcers?" In a college health center, this is a question I hear fairly often, especially around midterms or finals. Certainly most of us have experienced stomach discomfort when we are anxious- whether that is nausea, cramping, diarrhea or pain- but the vast majority of people with those symptoms do not have actual ulcers. However, people who are stressed may have coping habits that CAN cause or trigger the development of ulcers, such as drinking too much alcohol (more than one drink/day for women, or more than 2 drinks/day for men) or frequent use of over the counter pain killers known as NSAIDs (Non Steroid Anti Inflammatory Drugs) like ibuprofen (aka. Advil/Motrin/etc).

Stomach ulcers, meaning an abrasion or "ulceration" in the inside lining of your stomach, are actually primarily caused by a bacteria called H. pylori, which lives in the GI tracts of approximately 30-40% of Americans. It may be present for decades before it causes any symptoms. This bacteria is identified within 70-95% of ulcers that are biopsied in the stomach and the first part of the small intestine, the duodenum.

What are symptoms of stomach ulcers?
The discomfort of ulcers starts off feeling like hunger to many people- a deep ache, located below your breastbone and above your belly button. The pains may come and go at first, and may also be associated with feeling nauseated or bloated after meals. Initially, taking an antacid such as TUMS will relieve this sensation. The timing of the pains tends to vary with the location of the ulcer, and the pains might come and go for weeks at a time.

How does a doctor check for ulcers?
For young people (under 55 years) who are otherwise healthy, the current standard of care is to test for the presence of H. pylori bacteria, and treat immediately if that is positive. There are blood tests, breath tests and stool tests available. For older patients or those with risk factors for stomach cancer, direct visualization with endoscopy is recommended to allow the doctor to biopsy any suspicious areas.

How are ulcers treated?
If your doctor finds H.pylori, you will be treated with not one, but several medications: one acid blocking medication called a proton pump inhibitor, and two antibiotics. There are different regimens, but all include at least these medications at different dosages and timing.

BOTTOM LINE: If you are having recurrent pain in your upper abdomen, stop taking NSAIDS and drinking alcohol, and head in to see your doctor to be tested for H.pylori. Oh, and stop blaming your teacher for your ulcer...