Can Ovarian Cancer Be Found Early?

Ovarian cancer is the deadliest of all pelvic cancers for a woman. Overall, about one in seventy-two women will develop this disease. Of these, over half will have died within five years of diagnosis. If ever a disease cried out for a screening test, this would be it. Unlike the breasts, for example, the ovaries lie deep within the body and are therefore less accessible to physical exam. The bimanual pelvic exam is also uncomfortable and the discomfort causes women to tighten the abdominal muscles, making detection that much more difficult. If you add factors such as obesity and scars from Cesareans, you find the examiner's ability to feel the ovaries decreases exponentially.

Ultrasound has been suggested as a screening technique since the 1980's. In the US, the leading proponent of transvaginal ultrasound for ovarian cancer screening has been Dr. Van Nagell's group at the University of Kentucky.

Some have tried utilizing blood markers such as CA-125. Most recently, the group at MD Anderson found that evaluating changes in the level of CA-125 over time and combining that with transvaginal ultrasound yielded promising results in finding more early ovarian cancers.

Others, however, have not met with similar success. The US Preventive Services Task Force, in fact, recommends not screening for ovarian cancer.

Later this year, The UKCTOCS,the largest randomized trial of screening will publish its results, hopefully shedding more light on this issue.

In the meantime, there are some women at significantly higher risk for ovarian cancer, those whose strong family history or genetic tests place in a high risk group. For this group of women, screening, with all its foibles, should be considered. For more information or to schedule an ultrasound, please call: (718) 925-6277.

Dad's Magic Moment

Everyone knows that the prenatal ultrasound provides the opportunity for mom to bond with her baby to be. Even before she first feels movement, seeing that tiny heart's beating, watching those movements, makes it all real. There is ample literature to describe the maternal bonding experience. But what about dad? Few have studied his reactions to the process - that is until now. Dr. Tova Walsh and colleagues at the University of Michigan interviewed 22 expectant fathers after they viewed a midtrimester ultrasound.

They found that the ultrasound experience was an important moment for men, establishing the reality of the coming child, and reassuring them that all was going well with the pregnancy.

It also caused the men to reflect on their roles in the life of mother and child, making it an important practical and psychological preparation for parenthood. The study noted that the men’s “plans and dreams alike extended beyond the immediate future of infancy and across the child’s lifespan.”

One man told the researchers, “Now that we know that it’s a girl, you know, now I’m thinking about ... walking her down the aisle someday, you know, (I’m) thinking that far ahead ... which is crazy, but I mean, it’s like my brain went from bringing her into the world and taking care of her and making sure she is taken care of (as) to her future and everything ...”

Another had more immediate worries: “I need to make sure I have a steady job because my child eating depends on me. If I don’t work, he don’t eat. And I’d rather my child eat before I do.”

Dads have magic moments too.

Walsh is a Robert Wood Johnson Foundation Health & Society Scholar at the UW School of Medicine and Public Health. Her study, “Moving up the Magic Moment: Fathers’ Experience of Prenatal Ultrasound,” is being published in the winter 2014 edition of the journal "Fathering".

For more information, or to schedule an appointment for an ultrasound, call: (718) 925 - 6277.

Abnormal Bleeding - My Doctor Scheduled An Ultrasound

Abnormal bleeding is one of the most common reasons for a woman to seek medical attention. About ten to thirty percent of reproductive age women will experience some form of menstrual disturbance. There is a whole laundry list of causes, including stress, underlying hormone imbalance, tumors, clotting disorders and even cigarette smoking. While a disturbance in the normal hormone fluctuation may be the most common reason, it is not the only cause. For this reason, an ultrasound is often performed, usually with transvaginal views. The transvaginal approach obviates the need for that overly filled bladder and can often more easily see pathology such as submucus fibroids or endometrial polyps. The thickness of the uterine lining can also be measured as well.

Sometimes, a 3D sonogram is done to note the architecture of the uterine cavity and to further delineate suspected intracavitary pathology. Finally, if either there is the suspicion of focal pathology or to amplify the findings from the sonogram, a saline sonohysterogram can be performed.

Depending on the results of these tests, further evaluation and treatment can be discussed. For more information or to schedule an ultrasound, call: (718) 925 - 6277.

My Placenta Is Low-Lying. Now What?

Now that most pregnant women have a midpregnancy ultrasound, they are often alerted to findings of uncertain significance. One of the most common of these involves the placenta. A placenta is low-lying when the lower edge extends to within 2 centimeters of the internal cervical opening or os. This is different from a placenta previa which actually covers the internal os. A group of investigators at the Brigham and Women's Hospital in Boston reported on their experience with the eventual outcome of pregnancies complicated by these low placentas.

Here's the short answer: Most of these situations resolve by the end of the pregnancy.

In total, 1220 of 1240 low-lying placentas (98.4%) that had sonographic follow up resolved to no previa before delivery; 89.9% of placentas cleared the cervix by 32 weeks, and 95.9% cleared by 36 weeks.

A small minority were not so lucky.

Twenty patients (1.6%) had persistent sonographic placenta previa or a low-lying placenta at or near term, including 5 complete previas, 7 marginal previas, 5 low-lying placentas, and 3 vasa previas; all had cesarean deliveries.

So, about 98/100 times all turns out well. In about 2/100 cases, the situation persists. Moreover, a very few unfortunate women were found to have vasa previa, a condition in which fetal blood vessels actually cross that internal os in front of the baby. Think about that for a moment. If the baby descends toward the birth canal and puts pressure on these blood vessels, those vessels can tear, resulting in a fetal hemorrhage, often severe.

So what should be the plan if they do find a low-lying placenta during your ultrasound? The authors suggest a repeat sonogram after 28-30 weeks to confirm resolution, repeating again at 34-36 weeks if the situation remains the same. During those studies, a search for vasa previa can also be conducted.

So if you're told you have a low-lying placenta, you should be optimistic but should follow up. The late Ronald Reagan said it best: "Trust but verify."

For more information or to schedule an ultrasound, please call: (718) 925-6277.

New UK Project To Improve Prenatal Detection of Birth Defects

Presently, most if not all pregnant women undergo at least two sonograms during pregnancy for the purpose of screening for serious birth defects - the first at 11.5 - 14 weeks and the second at about 20 weeks. While some abnormalities are virtually always detected, many still are missed for a variety of reasons. For one thing, mom's with increased weight gain pose a technical imaging problem as the ultrasound frequency necessary for sufficient penetration may not yield the optimal resolution. Another factor is the fetal position - "if the baby has his back to the camera, you don't get a good picture." For these reasons and more, a groups of investigators at Kings College London are trying to see if technology can solve these issues.

Professor Reza Razavi and colleagues at King's College London, as part of King's Health Partners Academic Health Sciences Centre, have been awarded funding under the joint Wellcome Trust and EPSRC Innovative Engineering for Health scheme to develop a fully automated and computer-guided ultrasound system, which will allow midwives to acquire three-dimensional images of a whole baby in a much higher resolution than is currently possible. The team are also aiming to develop computer software that will be able to automatically analyse the images acquired. These techniques should substantially improve detection rates of congenital abnormalities.

Professor Razavi, who is Head of Imaging Sciences at King's College London and Director of Research at King's Health Partners, said: "Identifying birth defects at an early stage is essential both for medical professionals and for the parents themselves. Current ultrasound scans are relatively crude and many serious abnormalities are not detected, leading to these babies becoming very ill soon after birth, and substantial delay before a diagnosis is made and they can be transferred to a specialist centre for appropriate treatment.

"We are developing a radically new approach to fetal screening, largely removing the need for experts to acquire and interpret the images. It will allow the initial screening scans to be done in a few minutes, and provide a consistently higher detection rate for major abnormalities."

I wish them well.

For more information or to schedule an appointment for an ultrasound, call: (718) 925-6277.

Irregular Cycles May Be More Than An Annoyance

It's been a theory that infrequent ovulation may have some beneficial effect at lessening the risk for ovarian cancer. Women who take oral contraceptives, for example, have a lower incidence. This protective effect of irregular cycles may not always hold true. At the recent American Association for Cancer Research (AACR) meeting, Barbara Cohn, Director of Child Health and Development Studies at the Public Health Institute in Berkeley, CA presented some evidence that irregular cycles may actually be a risk factor for later development of ovarian cancer.

Background. Early detection of ovarian cancer has proved elusive, resulting in poor survival. This is the first prospective study to link a common reproductive condition to risk. Polycystic ovarian syndrome (PCOS) is an endocrine disorder, characterized by irregular menstrual cycles with long-term health consequences. Although some women with PCOS are infertile, the majority achieve pregnancy. It has been suggested that women with less frequent ovulation are protected, however, previous reports are inconsistent. Here we examine whether irregular cycling is associated with subsequent ovarian cancer death in a large prospective pregnancy cohort, The Child Health and Development Studies.

Methods. Subjects were 14,403 pregnant women recruited from the Kaiser Permanente Health Plan in 1959-1967 and followed for over 50 years. Menstrual irregularity, cycles >35 days or anovulation, was a proxy for PCOS, identified from medical record and self-report, at a median age of 26 years in 13% of women. Linkage to California Vital Statistics and National Death Index records identified 64 ovarian cancer deaths diagnosed at a median age of 69 years.

Results. Contrary to expectations, women with irregular cycles had a two-fold greater risk of ovarian cancer (Hazard Ratio=2.4; 95% Confidence Interval=1.3,4.5), independent of age, race, parity, and weight. This association was specific to cancer of the ovary - no association was observed for breast or uterine cancer - and it increased over the follow-up period (p=0.08 for time-dependence).

Conclusions. This is the first large prospective study of irregular cycles as an early marker of ovarian cancer. If confirmed, women with irregular cycles could be targeted for screening. This finding offers a strategy to search for antecedent ovarian cancer biomarkers, creating the opportunity for new early detection strategies.

It's not clear what exactly is going on here. Could later cancer be a side effect of abnormal hormone fluctuations? Could this be a receptor issue in the ovary iteslf? Or could the underlying cause of the hormone pathophysiology be the culprit? It's far too soon to know the answer but further research is clearly needed.

At this point, the best advice is to discuss your concerns with your gynecologist. For more information or to schedule an appointment for a pelvic ultrasound, please call: (718) 925-6277.

Maternal Weight And Stillbirth

This past week in the Journal of the American Medical Association, a statistical analysis of 38 studies of moms' weight either prior to pregnancy or in early pregnancy showed a relationship between maternal BMI and risk of stillbirth. The loss of a wanted pregnancy at any gestational age is tragic but the worst has to be a fetal death in the few weeks prior to birth. The nursery has been set up. The birth announcements prepared. Often, the room is packed with gifts from the baby shower. All this adds to the immense suffering of the loss of a child.

So how is maternal weight linked to stillbirth? The authors suggest the possibility that the increased amount of adipose tissue may exert metabolic effects which affect placental function. We already know the effect of weight, fat, and type 2 diabetes, for example. A similar altered biology may be at work here as well. Another possibility is that heavier women become less sensitive to fetal movement and are thus less apt to pick up on the signals of decreasing fetal movement. The lack of this alarm mechanism may miss that narrow window for life-saving intervention.

So what should a woman considering having a baby do in light of this information? The best, obviously, is to get as close to ideal body weight as possible prior to conception. When this is not possible, early prenatal care would be essential, with a special emphasis to nutritional counseling. As pregnancy enters the "home stretch," certain tests of fetal well-being can be considered - monitoring or non-stress tests, serial ultrasounds for fetal growth, and biophysical profiles. Additionally, fetal kick counts can be done at home which require no sophisticated equipment.

Moms to be should voice any concerns with their Obstetricians. For more information, or to schedule an appointment for an ultrasound, you can call my office at: (718) 925 - 6277.

JWoww's Pregnancy Scare

Jenni Farley aka JWoww of "Jersey Shore" fame (or infamy) described the impact of learning about a minor abnormality in her prenatal ultrasound.

Jenni reported on her blog recently that a routine ultrasound turned into a moment of pure terror when her doctor informed her that he identified what may be a cyst on the fetus' brain. "At this point I honestly can't tell you what he's saying because I go numb and tears are just flowing," Jenni wrote of the incident. A scary diagnosis, to be sure, but using her trademark tenacity, Jenni secured an appointment with a specialist who delivered some good news: Jenni writes that the new doc informed her: "It's called choroid plexus cyst and over time the cyst should go away." She added, "Honestly I was happy but still my heart felt heavy. And even though I know I did nothing to cause it, I felt guilty and so helpless." Well, apparently Jenni has developed a skill for suspenseful storytelling during her months of sobriety because she ends the blog post by revealing that this all happened several weeks ago: "Fast forward to this check-up which brings me to 25 weeks aka 6 months," JWoww writes. "My daughter's cyst went away!"

There are a variety of findings whose significance seems relatively minor to obstetricians and sonographers yet strike fear in the hearts of moms to be. Choroid plexus cyst is one of these findings. Choroid plexus cyst or CPC is a small fluid-filled structure found in the choroid tissue in the ventricle of the developing fetal brain. CPC's are found in about 1 - 2% of all fetuses so these are quite common. While earlier descriptions found an association between CPC and Trisomy 18 (an extra copy of chromosome 18,) this association has not panned out in further investigations. CPC's do not cause swelling on the brain or hydrocephaly. They are not in and of themselves a major abnormality and have no effect on mental development. In the absence of other risk factors for chromosome problems, eg. age, family history, previously affected children, or other malformations, these should not warrant either worry or further investigation. In fact, most, as in Ms. Farley's case, resolve spontaneously.

For more information, or to schedule an appointment, please call my office: (718)-925-6277.

Bloody Cycles

The transition to menopause is thought to consist of increasingly prolonged intervals between menstrual flow. The recently published SWAN study, however, suggests that early in that transition, the frequency of heavier and longer cycles may be far more common.

... We found that the large majority of women in SWAN, over 50% of whom were not white, reported menses duration of 10+ days, spotting of 6+ days and/or 3+ days of heavy bleeding during the MT. The likelihood of experiencing these menstrual bleeding events varied by race/ethnicity, BMI and reported uterine fibroids. These data confirm that two types of bleeding, longer menses with more days of spotting and heavier menses, occur in most women during the MT. These data provide clinicians and women with important normative data regarding the expected frequency of these bleeding changes during the menopausal transition, data that may facilitate decision-making in clinical practice. Such information, particularly when coupled with the emerging information about duration of the stages of the menopausal transition, will be of great value to women in this life-stage who wish to be active participants in their own health care. Such normative data can greatly alleviate concerns about midlife changes in ones bleeding patterns and facilitate coping with what, in most cases, will probably be a time-limited experience. Further research on the correlation between such bleeding and documented pathology is warranted to better support recommendations for watchful waiting versus clinical intervention.

Changes may be marked by differences in estrogen and progesterone production, signifying either greater or fewer ovulatory episodes. These changes may also signify underlying pathology such as uterine fibroids, adenomyosis, polyps or even hyperplasia. The last is especially troubling as prolonged estrogen stimulation without the periodic interjection of progesterone may lead not only to unscheduled bleeding but in a few cases, cancer.

A transvaginal sonogram is a simple test to gauge the thickness of the endometrial lining and should be considered as an integral part of the workup for abnormal bleeding. For more information, or to schedule an appointment, you can call my office at North Shore LIJ: (718) 925-6277.

Humbling

It's really something when you receive props from your peers. Over the weekend, the Medical Society of the State of New York had its annual House of Delegates. At that meeting, officers were elected. One of the new officers is yours truly.

Tarrytown, NY (4/14/14)--Arthur C. Fougner, MD, was elected Assistant Secretary of the Medical Society of the State of New York (MSSNY) at its 208th annual House of Delegates (HOD) meeting in Tarrytown, NY, on April 12. Board certified in Obstetrics and Gynecology, Dr. Fougner is Chief of Gynecologic Ultrasound at North Shore LIJ.

A graduate of the University of Notre Dame, Dr. Fougner earned his MD degree from Tulane University School of Medicine. He completed his postdoctoral training in OB-GYN at St. Clare's Hospital, NYU Medical Center, Bellevue Hospital and Booth Memorial Medical Center.

An attending OB-GYN at North Shore University Hospital, Long Island Jewish Medical Center and Forest Hills Hospital, Dr. Fougner is an assistant professor of OB-GYN at the Hofstra North Shore- LIJ School of Medicine at Hofstra University and formerly an assistant clinical professor at SUNY Stony Brook and Albert Einstein College of Medicine.

Dr. Fougner is a member of the International Society for Ultrasound in Obstetrics and Gynecology and of the American Institute of Ultrasound in Medicine.

Active in organized medicine since 1979, Dr. Fougner served as MSSNY's Commissioner of Communications from 2012-2013. He previously served as MSSNY's Assistant Commissioner of Public Health from 2009-2010 and Commissioner of Governmental Affairs from 2010-2012. He serves as both a trustee and a Councilor for the Medical Society of Queens.

Founded in 1807, the Medical Society of the State of New York is the state's principal non-profit professional organization for physicians, residents and medical students of all specialties. Its mission is to represent the interests of patients and physicians to assure quality healthcare services for all.

http://readme.readmedia.com/Arthur-C-Fougner-MD-Elected-Assistant-Secretary-Of-State-Medical-Society/8430504

I guess every organization needs a Marv Throneberry.

I am truly humbled.

Hepatitis C: To Screen Or Not To Screen, That Is The Question

Recently, NY State passed a law requiring screening for Hepatitis C be offered to all patients born between 1945 - 1965. Hepatitis C is a potentially fatal disease which can attack the liver silently over time. It is thought that as many as 1 in 30 "Baby Boomers" could be infected with the virus. For these reasons, screening this group makes sense. But of course, as always, there is a catch. It seems the cost of treatment for those infected is prohibitive for all but those on research protocols, better than platinum insurance plans, or those with incomes in the Warren Buffett range. Sovaldi, a new drug for Hep C treatment, costs about $84,0000 for a 12 week treatment.

What can be done about the cost? Right now, not much save to check with your insurer about treatment coverage and copay, etc. Still think screening asymptomatic folks is a good idea? For each individual, the answer may be different. Before asking a question, it's always best to know what you'll do with the answer.

You Now Have Health Insurance - Now What?

Now that Open Enrollment in Individual Health Plans is over (for most folks,) what do you do now?

For starters, go to either the webpage or the healthplan's book and check out what it is you actually purchased. You need to know three numbers - your premium, of course, your co-pay, and your deductible. When you selected your plan, you should have noted each of these numbers but many haven't. Please note them now for the true cost of your plan is not merely the monthly premium.

Now look at the "Provider Book" or the list of so-called Healthcare Providers on the plan website. Being a physician, let me point out that I didn't go to "Provider School." But that's a matter for another day. If you have an ongoing relationship with a doctor, make sure that your doctor is on the network list. If you can't find this information, call the plan's info number and find out. Again, you should have checked this out before choosing a plan, but that's water under the bridge now. Most if not all of the new individual plans set up under the "Affordable Care Act" are In-Network only plans and these networks are usually quite narrow with fewer choices. If after calling the plan and/or your doctor's office, emailing the plan, or sending out an APB, you still can't find out if your doctor participates in this plan, alert your state's insurance department. In NY State, that would be under the Department of Financial Services. Unfortunately for many, you may have to choose a new Primary Care Physician and you should do so asap. If you have a chronic illness for which you are undergoing treatment, you also have to find out if your specialist doctors are "in network" as well. If not, sadly, you will have to choose whether to pay a rather large bill for care or switch to a whole new set of treating physicians and start from square one.

Here's the problem - these new plans are for the most part "In Network" only. That means that whatever benefits your plan involve services provided only by In Network Providers. There are NO Out of Network Benefits for most Individual Plans save for a few scattered exceptions. If you need to go "Out of Network," the insurance version of "Off the Res," NONE of those services will be covered unless you get a special dispensation from the plan's hierarchy, usually the Medical Director. For example, if you have advanced colon cancer and wish to be treated at a Cancer Center like NY's Sloan Kettering which you find is not in your network, expect that you will be responsible for the entire bill. Moreover, and here's the kicker, none of the money you shell out will count toward your plan deductible - zip, zero, nada.

If you do not think this is fair, you are not alone. Unfortunately, the law isn't about fairness and it is what it is. My suggestion is that while you're still upset, you contact the State Insurance Dept (Again, in NY State, the Dept of Financial Services) and register a complaint. You should also call your state legislator and your local news consumer affairs reporter. The more light you shine on this issue, the sooner this will be dealt with. Everyone in NY State I've spoken with has acknowledged this problem with the individual plans.

Now, you may luck out. You may be healthy, not need care, and, if you do, find In Network doctors who are competent, caring and professional to handle your medical issues. But it shouldn't be left to luck, chance or God, should it?

Realize also that many doctors are in the same boat. It seems the plans were not so forthcoming at giving doctors the choice of either joining an insurer's new plan networks or informing them that they were either in or out of the new narrow network. This is a recipe for chaos. Also, if the plan lists a doctor as In Network but the doctor really is not, you will assuredly get a bill. And as I pointed out above, that bill will not count toward your deductible.

In reality, most of these plans are the worst of all worlds - an amalgam of an old HMO with a High Deductible Plan. There's little anyone can do about this situation right now, unfortunately. If you do run into a problem, please don't take it out on the doctor. Most of the doctors I know have been pleading with the states to do something as the end of enrollment approached. During the Second World War, the motto in Britain was "Keep Calm And Carry On." Both doctors and patients will need to do that. However, that doesn't mean you shouldn't complain. You should. For sure, it really is the squeaky wheel that gets the grease.

One last suggestion - other resources you should consider are your County and State Medical Societies. They have dedicate staff who are well-acquainted with the situation and are well-positioned to get you advice and also, to pursue your issues as they meld with their doctors' issues.

"Fasten your seatbelts, it's going to be a bumpy night." Bette Davis