Author Archives: Martha Bebinger

Martha Bebinger covers health care and other general assignments for WBUR. She was a Nieman Fellow at Harvard University, class of 2010.

Pathologist: What Women Need To Know About Breast Biopsy Accuracy

A breast biopsy which illustrates the grey zone of pre-cancer (Courtesy of Dr. Michael J. Misialek)

A breast biopsy which illustrates the grey zone of pre-cancer (Courtesy of Dr. Michael J. Misialek)

By Michael J. Misialek, MD

If you’re a woman who has ever had a breast biopsy, you may be asking yourself a few serious questions:

“How do I know if my breast biopsy is completely accurate?” And, “Who is the pathologist reading the biopsy, and what is their level of training?”

Many more patients are asking these and similar questions following widespread media coverage on a Journal of the American Medical Association (JAMA) study, which casts doubt about the accuracy of interpreting these biopsies.

Let’s break the study down and ease some anxiety. Perhaps most importantly, this provides a great opportunity to learn about one of the lesser know medical specialties, pathology…which is what I do.

The JAMA study, “Diagnostic Concordance Among Pathologists Interpreting Breast Biopsy Specimens,” revealed the following key finding:

• Overall agreement between individual pathologists’ interpretations and that of an expert consensus panel was 75 percent, with the highest agreement on invasive breast cancer and lower levels of agreement for ductal carcinoma in situ (DCIS) and atypical hyperplasia.

What this means is that the agreement between a general pathologist and an expert was excellent for breast cancer (those with the ability for metastasis), but varied significantly for early cancers and high-risk pre-cancers.

While the study’s findings may not be surprising to physicians who understand the challenges of diagnosing complex breast cases, news of the article could lead to unnecessarily heightened anxiety for patients and the public as breast cancer is a highly publicized and pervasive disease.

The study confirmed that the majority of breast pathology diagnoses, especially at either end of the spectrum (benign disease and invasive breast cancer) are accurately made by practicing pathologists regardless of practice setting. The overall rate of agreement for invasive breast cancer cases was 96 percent.

Issues with diagnostic disagreement mainly center on the borderline cases, between atypical hyperplasia, that is, pre-cancer, and DCIS, early cancer.

Why does this matter? Overdiagnosis can lead to unnecessary surgery, treatment and anxiety. Underdiagnois can lead to a delay in treatment. The bottom line is that experience matters.

Factors that contributed to greater disagreement included: a low case volume, small practice size, nonacademic practice and high breast density.

The study has many weaknesses. Chief among them was that only a single slide per case was given to each pathologist. As a practicing pathologist, this never happens. I will review multiple slides, often ordering several additional deeper sections and ancillary special stains, studying each carefully. This practice was prohibited in the study.

Additionally, the study cases were a mixture of core biopsy and excision specimens. A core biopsy is obtained using a needle, often by a radiologist, in which a small core of tissue is removed. An excision is a “lumpectomy” which is done in the operating room where a large section of breast tissue is removed. Diagnostic criteria vary between a needle core and excision. Often times it is not necessary to render an exact diagnosis on the core biopsy, but rather recognize an abnormality and recommend an excision for which additional tissue will clarify the diagnosis.

Even the experts disagreed in the study (75 percent initial agreement then 90 percent after discussion).

This illustrates the fact that pathology is both a science and art. Experts may stress slightly different criteria in their pathology training programs. The “eye of a pathologist” is a difficult measure to quantify and is dependent on multiple factors that best function in real time, not an artificial study.

Another weakness is that there is no evidence that the experts were more accurate in predicting outcomes than test subjects. Perhaps most importantly, a second opinion was not allowed in the study, even when study participants indicated uncertainty. These are in fact the very cases that would most likely have been shown around, sent out for consult and further worked up.

It is not realistic to introduce such a large caseload of breast biopsies that are heavily weighted towards atypical hyperplasia and DCIS. Since these borderline cases represent only a small fraction of breast biopsies in actual practice, diagnostic agreement in routine practice is higher than that reported in this study. No clinical information other than patient’s age was given to the study pathologists, and no imaging findings were included. In actual practice, integration of the clinical setting and imaging findings is routinely used in making a diagnosis.

The findings are not unique to pathology. All of medicine has grey zones, where controversy often exists. The study does have an important message for pathologists. As noted in the accompanying editorial, it should serve as a “call to action.” A better, more reproducible definition of atypical hyperplasia is needed.

The article highlights the need for an active quality management program in surgical pathology that includes targeted review of difficult or high risk cases. The College of American Pathologists (CAP) and the Association of Directors of Anatomic and Surgical Pathology have been developing an evidence-based guideline expected to be released in May to provide recommendations to reduce interpretive diagnostic errors in anatomic pathology.

The CAP is proactively addressing educational opportunities through advanced breast pathology training programs designed to provide a route for pathologists to demonstrate their expertise regardless of the setting in which they practice.

Patients can take steps to help ensure their breast biopsy is read accurately:

o Inquire about the pathology laboratory that will examine your tissue sample. Is the laboratory accredited? The CAP accredits more than 7,600 laboratories worldwide and provides an online directory for patients. Continue reading

Study: A Simple, Cheap Way To Help Low-Income Kids With ADHD

Boston Medical Center (Wikimedia Commons)

Boston Medical Center (Wikimedia Commons)

Say you’re a pediatrician whose 8-year-old patient is showing symptoms of Attention Deficit Hyperactivity Disorder. That’s not unusual, up to 12 percent of American kids are diagnosed with it.

But you know that in general, ADHD treatment tends not to work as well in poor kids, like your patient, as it does in their better-off peers. And you also happen to know that the symptoms began two months after the patient’s father was incarcerated. It might be ADHD, or it might just be horrible stress. What do you do?

This is the kind of challenge that routinely faces pediatricians at Boston Medical Center, where most of their patients comes from the inner city, says Dr. Michael Silverstein, chief of the hospital’s division of General Academic Pediatrics.

In a study of 156 young patients just out in the journal Pediatrics, Silverstein and colleagues report some success with an experimental intervention they designed to address such challenging cases.

They found that with a relatively modest investment — about a week of training for a care manager that the patients’ families interact with anyway — they could “move the needle” on ADHD symptoms and social skills, he says.

I asked him to elaborate. First, the background:

General pediatricians tend to be fully equipped to treat straightforward cases of ADHD, Dr. Silverstein says, but for tougher cases like the one described above, and many among BMC’s population of vulnerable kids, they need specialists to address the more vexing issues. One proven model of providing that expertise is called “collaborative care.”

Providing care for low-income kids through mechanisms that address the health of both generations, parents and children.

The pediatrician is “driving the boat,” he says, but the specialists “essentially provide what we call ‘decision support.’ They say, ‘For someone like who you’re describing to me, I would try something like this.’ They give the rules of the road to the primary care doc, but the primary care doc drives.

And because it’s so hard to get busy people into the same room at the same time, the communication between the primary care doctor and the specialist is mediated through a ‘care manager’ intermediary.” (Ideally, a child psychiatrist would be right down the hallway, but that’s “pie in the sky” for under-resourced hospitals like the BMC, he notes.)

Research has shown that collaborative care works well, “but at BMC and places like it, this way of delivering care is probably necessary but not sufficient.” The reason? “A lot of kids with symptoms of ADHD don’t get better even when treated optimally. Why is that? You give them access to proper medication, the diagnosis is made properly, yet they don’t get better. And we homed in on three reasons that kids with ADHD symptoms may not get better that really were relevant to our population:

• The first is that we know that parents of children with ADHD have a disproportionate burden of mental illness themselves. You could imagine a child’s improvement trajectory might not be as good if his mother is depressed.

• Also, in general we see a guardedness about going to the doctor for behavioral problems — that’s not in everyone’s cultural frame of reference. So the idea of medication for inattention might not be where everyone is at. These are potentially stigmatizing conditions, so lots of times people recommend a course of action — medication or something else — but the families aren’t quite there.

• And the third reason is that we know that for certain children with ADHD, behavioral therapies work really well in addition to medication, but our families tend not to have access to those.

So we developed an intervention that was hung on the structure of collaborative care, where the care managers who serve as intermediaries between specialists and generalists are trained to address those three things. Continue reading

Not Male Or Female: Molding Bodies To Fit A Genderfluid Identity

From left to right, Devon Jones, Dale Jackson and Taan Shapiro. (Courtesy)

From left to right, Devon Jones, Dale Jackson and Taan Shapiro. (Courtesy)

For more than three years, Devon Jones gave himself weekly shots of testosterone to align his body with the feeling that he was male. The shots worked. Jones’ voice dropped, body fat shifted from his thighs and breasts into his neck and stomach, and he sprouted facial hair.

But then last year, Jones, a 27-year-old author who lives in Dorchester, stopped taking the hormone.

“I realized that wasn’t the look I was ultimately going for,” Jones said. “I wanted to still have breasts that had substance to them, they’d really shrunk and I wanted that back.”

And Jones wants the option of getting pregnant and having a child, something he could not do while testosterone overpowered estrogen in his body. It’s not clear if he will be able to get pregnant now.

“I’ll only know that when I try,” he said.

Jones still use male pronouns. The changes to his voice are permanent. But as estrogen again becomes the dominant hormone in Jones’ body, the hair on his face doesn’t grow as quickly and his body fat has shifted back.

“I have a more curvy feminine shape. I’m more comfortable now with people being confused. So it’s an evolving process. It’s weird to be in the middle of it right now actually, and talking about it,” Jones said, his voice trailing off.

Jones is part of a growing group of young adults who are genderfluid and are using hormone therapy and surgery to create bodies that matches this identity.

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What To Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)

Screen shot 2015-03-20 at 9.07.11 AM

By Ananda Lowe
Guest Contributor

The term “homebirth cesarean” didn’t exist before 2011, when Oregon mother and student midwife Courtney Jarecki coined it. But now, a Google search returns almost 2,000 entries on the topic.

The term refers to a small but emerging community of mothers who have experienced the extremes of birth: They’d planned to have their babies at home, but ended up in a hospital, most often in the operating room having a cesarean section, major abdominal surgery. Needless to say, the effect of such a dramatic course change takes a toll, and can often be overwhelming.

(“Homebirth cesarean” can also refer to births that were planned to occur at a freestanding birth center outside of a hospital, but eventually were transferred to the hospital for a cesarean.)

How often does this happen?

Home births, though a small fraction of the approximately 3.9 million births a year in the U.S., are on the rise. Based on the most recent birth data from the National Center for Health Statistics, “the 36,080 home births in 2013 accounted for 0.92% of all U.S. births that year, an increase of 55% from the 2004 total.”

Eugene Declercq, a professor of community health sciences at Boston University School of Public Health, studies national birth trends. He said in an email that while there are no nationwide numbers on homebirth transfers to the hospital, “the studies that have been done usually report about a 12% intrapartum transfer rate.”

But beyond the numbers, what happens emotionally when your warm and fuzzy image of natural childbirth in the comfort of home suddenly morphs into the hard reality of a surgical birth under fluorescent lights?

A woman who'd planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

A woman who’d planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

Jarecki founded the homebirth cesarean movement to figure that out. She connected women who, like herself, shared the experience of giving birth through full surgical intervention, despite their original plans of having their babies at home or outside of the established medical system.

In Jarecki’s case, she labored at home for 50 hours until her midwives detected a rare complication known as a constriction ring, or a thickened band of tissue in her uterus that was impeding progress. Shortly after this, meconium appeared, and Jarecki knew it was time to go to the hospital. Her emotional response to the intensity of the situation, however irrational, was one of anger, shame and failure at her ability to give birth normally. A cesarean followed.

Over the next several years, Jarecki began helping other homebirth cesarean mothers emerge from the silence and shame they felt confronting their unexpected surgeries. Some of these women also report that their postpartum recovery was tougher because their unique needs were not adequately addressed by their home birth midwives or their hospitals.

Jarecki started by launching a (now busy) Facebook page as a support group for these mothers and their health care providers.

Childbirth Expectations vs. Reality

Rule number one in childbirth is that it rarely unfolds as you expect. Continue reading

Federal Mental Health Chief Calls Rising Suicide Rate ‘Unacceptable’

Dr. Tom Insel is a neuroscientist and psychiatrist, and he’s been the director of the National Institute of Mental Health (a division of the National Institutes of Health) since 2002. He recently helped lead the development of “A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives” with the National Action Alliance for Suicide Prevention. WBUR’s Lynn Jolicoeur spoke with him about the state of research into and understanding of suicide.

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The Science Of Suicide: Researchers Work To Determine Who’s Most At Risk

Harvard psychology professor Matt Nock and research assistant Nicole Murman demonstrate the Implicit Association Test related to suicide risk. (Robin Lubbock/WBUR)

Harvard psychology professor Matt Nock and research assistant Nicole Murman demonstrate the Implicit Association Test related to suicide risk. (Robin Lubbock/WBUR)

Part of an occasional series we’re calling “Suicide: A Crisis In The Shadows

BOSTON — Up on the 12th floor of a nondescript concrete building in Cambridge, about a dozen Harvard University researchers spend their days trying to crack the code on something that’s eluded scientists for decades.

“We’re really lacking in our ability to accurately predict suicidal behavior and to prevent it,” says psychology professor Matt Nock, who runs the so-called Nock Lab, which is focused entirely on suicide and self-harm. “We are really struggling with identifying which people who think about suicide go on to act on their suicidal thoughts and which ones don’t.”

Nock demonstrates a computer-based exercise he’s using in his research, known as the Implicit Association Test, or IAT. The test asks patients to quickly classify words related to life or death — such as “thriving” or “suicide” — as being like them or like other people.

“For suicidal people, they’re faster responding when ‘death’ and ‘me’ are paired on the same side of the screen. People who are non-suicidal are faster responding when ‘death’ and ‘not me’ are paired on the same side of the screen,” Nock explains.

He and his team are evaluating the test by trying it out with patients in the psychiatric emergency room at Massachusetts General Hospital. The study participants do one other word classification exercise called Stroop and answer questions about addiction, mental illness and suicidal thoughts or behavior. Continue reading

Dementia As A Global Public Health ‘Tidal Wave’

We often think of dementia as a private, intimate hell. A mother no longer recognizes her daughter’s voice. A father rages incoherently at a family dinner.

But it’s worth remembering the global scope of dementia; it’s a looming, worldwide public health disaster, a ‘tidal wave,” as the head of the World Health Organization recently put it, that’s growing worse each year.

This week, the World Health Organization held the first-ever ministerial conference calling for global action against dementia, saying, essentially, enough already, this is something we really need to deal with now.

The WHO’s Director General, Dr. Margaret Chan, offered some sobering perspective in her opening remarks and noted that there are three specific reasons to act now: “Dementia has a large human cost. Dementia has a large financial cost. Both of these costs are increasing.”

According to remarks distributed by the WHO, Chan spoke of dementia, including Alzheimer’s, in dire terms:

“The world has plans for dealing with a nuclear accident, cleaning up chemical spills, managing natural disasters, responding to an influenza pandemic, and combatting antimicrobial resistance. But we do not have a comprehensive and affordable plan for coping with the tidal wave of dementia that is coming our way.”

And the numbers are staggering:

–Dementia currently affects more than 47 million people worldwide, with more than 75 million people estimated to be living with dementia by 2030. The number is expected to triple by 2050.

–Dementia leads to increased long-term care costs for governments, communities, families and individuals, and to productivity loss for economies. The global cost of dementia care in 2010 was estimated to be U.S. $604 billion – 1.0% of global gross domestic product. By 2030, the cost of caring for people with dementia worldwide could be an estimated US $1.2 trillion or more, which could undermine social and economic development throughout the world.

–Nearly 60% of people with dementia live in low- and middle-income countries, and this proportion is expected to increase rapidly during the next decade, which may contribute to increasing inequalities between countries and populations.

Continue reading

Wishing They Asked Tough Questions: Reflecting On A Father’s Suicide

Valerie Alfeo files through a table full of old family photos at her home in Waltham. Her father, Ted Washburn, took his own life in 2011. He was 54. (Jesse Costa/WBUR)

Valerie Alfeo files through a table full of old family photos at her home in Waltham. Her father, Ted Washburn, took his own life in 2011. He was 54. (Jesse Costa/WBUR)

Part of an occasional series, “Suicide: A Crisis In The Shadows

WALTHAM, Mass. — TJ Washburn first learned his father, Ted Washburn, was battling depression in 2009. That’s when the then-52-year-old starved himself for three days.

“He said basically that he was planning on not eating or drinking anything until he passed away,” TJ recalls. “And obviously shock kind of sets in at first.”

Ted, who lived in Waltham, spent a few weeks in two psychiatric units. And during that time his son was stunned to learn he had attempted suicide at the age of 21 — two years before he started having children.

“To think that he could have taken his life before I was born was something that was just… surreal is the best word that I keep using — that I can’t really imagine,” TJ says.

But in 2009, when their father got out of the hospital and right back into his routine as a truck driver, TJ and his sister, Valerie Alfeo, say he didn’t talk about his depression. And they didn’t ask much.

“I was scared. I mean, for me it’s half of the people who created me. You still have them on a pedestal to some degree, even at late 20s, early 30s,” TJ reflects. “I mean, I still would go to him, ask him for his advice. I guess I wasn’t prepared to be kind of on the other end, and be the one giving any advice.”

Continue reading

More Than 1,700 Reports Of Drug-Exposed Newborns Seen In Mass. Last Year

Massachusetts child welfare officials say they investigated more than 1,700 reports of drug-exposed newborns over the final 10 months of last year.

Over that period, the state saw a more than 40 percent increase in reports of drug-exposed newborns, from 132 instances in March 2014 to 190 in December, according to data provided by the Department of Children and Families. The December total was down from the agency’s peak recording of 236 in September that year.

Experts say it’s a sign of just how dire the state’s opioid epidemic has become.

Jonathan Davis, chief of newborn medicine at the Floating Hospital for Children at Tufts Medical Center, tells the Boston Herald that Massachusetts hospitals combined used to report two or three drug-exposed babies being born per day, but it’s now more like 10 to 15 per day.

Davis said several initiatives have been created to address the issue, pointing to Project Respect, which provides substance abuse treatment for pregnant women and their newborns at Boston Medical Center and serves more than 150 mother-baby pairs each year.

The state started tracking drug-exposed babies last March.

With reporting by The Associated Press and the WBUR Newsroom

Related:

How Contagious Is That Dinner Party? And How Best To Evade Friends’ Bugs?

(Faruk Ateş/Flickr)

(Faruk Ateş/Flickr)

“This is not a question for an expert on etiquette!” I expostulated. “It’s a question for an Infectious Disease specialist!”

The trigger for that objection: A query to Social Qs, the New York Times etiquette column on “awkward situations.” The writer describes a group of 10 close friends who meet regularly for dinner; one, who is immuno-suppressed, asks that another member who is getting over the flu and still on antibiotics keep 12 feet away and avoid touching anything she may eat. The reader asks: “Shouldn’t one of them have declined the invitation? But which?”

The columnist responds that no, no one needed to bow out, and that this distance-setting arrangement seems a good compromise, adding, “I hope the person with the flu called her doctor to make sure she was no longer contagious — for everyone’s sake.”

Surely you can understand my frustration. Fine, the flu patient could call her doctor, but what about the rest of us, hungry for more general knowledge on contagion for our own social gatherings? Why not answer the obvious questions? Like: Is 12 feet really far enough to avoid flu germs? Are you still contagious when you’re finishing a course of antibiotics?

Oddly, the day after I read that column, a similar situation played out at my house: One friend was getting over a respiratory infection, still coughing, and another friend regretfully said she could not stay and chat at the dining table, for fear of carrying a germ to an immuno-compromised loved one.

That did it. I called CommonHealth’s go-to guy on infectious disease questions of public interest, Dr. Ben Kruskal, chief of infectious diseases at Harvard Vanguard Medical Associates, and shared my annoyance. Actually, he gently corrected me, this is an issue of both medical science and etiquette. Our conversation, lightly edited:

Dr. Kruskal: You need to have the facts and then you can figure out the etiquette in light of them.

First, when it come to infectious disease transmission, we know a fair amount, but there’s a lot that is still argued over. So let’s take flu as a good example. We know that there are multiple mechanisms by which flu is transmitted, or by which you could postulate reasonably that it might be transmitted:

Dr. Ben Kruskal (Courtesy)

Dr. Ben Kruskal (Courtesy)

• Physical contact: You’ve got germs on your hands, you touch somebody else’s hands or face. Or indirect contact — you touch your face, and then touch the doorknob. A few minutes later, someone else touches the doorknob and then their face.

And there are two different mechanisms of airborne transmission:

• Respiratory droplets, which fall to the ground pretty quickly after they leave your mouth and nose. People argue about the distance they can travel — some people say three feet, some say six feet. Six is a very conservative estimate.

• And then there’s what’s called true airborne transmission (technically, droplet nuclei), which is the mechanism by which TB, measles and chicken pox are all transmitted. And that’s the kind that can go much longer distances and can linger in the air for a long time afterward.

So which is flu?

Flu looks like it’s probably mostly droplets, with some contact, and then there’s a lot of debate in the medical literature about whether there’s some component of airborne transmission or not. If it’s there, it’s probably not huge — we’re arguing whether it’s .1 percent or 1 percent or 5 percent, but it’s probably not more than that.

What else should we know? Continue reading