Family Medicine Notes

Today I called someone who may have cancer.  This is always a tough call, since at this stage, there are no clear answers yet.  We often know more about what things are NOT before we know what they are.

• "There is something on the ultrasound that looks suspicious"




• "What is it?"


• "I'm not sure"




• "Could it be ... ?"


• "Cancer?   Yes .. it could .. but it's not likely to be ..."




• "What should we do?"


• "We'll need to do some additional testing ... such as .. "

This is usually how it goes.  I always say the "C word" early in the conversation.  This gives us both permission to say it .. since it's always lurking in the background if we don't bring it out in the open.   Next, I need to reassure the patient that the likelihood of cancer is small.  This is often calming, but of course the worry persists.  Why do I say that the likelihood of cancer is small?  Because it usually is.  Much more often, abnormal findings are just abnormal findings. 

Of course we need to do our very best to follow through carefully, do appropriate and thorough physical evaluations, etc ... and not ignore abnormal findings.  Yet the fear of the "really bad" outcome can be enormous and unnecessary, since a great deal of the time, the final result is reassuring.

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Last week's billing episode now resolved .. I tackled one this morning much more promptly. 

6  months ago, I removed an infected sebaceous cyst from a patient's neck.  My progress note adequately described the procedure and the indications for the procedure.  The insurance company denied payment - insisting that it was a cosmetic procedure.  We submitted the note - and they denied it again.   So billing people call patient and tell her she must pay.  She says no way .. and calls insurance company and they say ... ok .. re-submit bill .. we will pay this time.  Bill got re-submitted in late May .. but patient still getting bills from us .. has appointment with me next week .. and our staff now being told to get the $$ from her when she comes.  Feels bad ... so I call insurance company and very nice lady tells me that check was mailed and we were paid! ... I say think you and hang up. 

.. but I wonder why it took so long .. and required so much effort. 

Another unfortunate reality:  being paid 6 months late after three submissions and many phone calls = a success.

Posted by Jacob Reider, MD at 09:32 PM | Permalink

From STI:

Here's the abstract. It's an interesting idea .. though I doubt the local HMO would cover it.

Zafirlukast for severe recurrent vulvovaginal candidiasis: an open label pilot study
D J White1, A Vanthuyne1, P M Wood3 and J G Ayres2
1 Hawthorn House, Department of Sexual Medicine, Birmingham Heartlands Hospital, Hospital, Bordesley Green East, Birmingham B9 5SS, UK
2 Department of Respiratory Medicine, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK
3 Department of Clinical Biochemistry and Immunology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK

Correspondence to:
Dr D J White
Hawthorn House, Department of Sexual Medicine, Birmingham Heartlands Hospital, Hospital, Bordesley Green East, Birmingham B9 5SS, UK; David.white@heartsol.wmids.nhs.uk

Background: Recurrent vulvovaginal candidiasis (VVC) has been linked to allergic disease, particularly allergic rhinitis.

Objective: A pilot study to assess the possible use of the leukotriene receptor antagonist zafirlukast as a treatment for recurrent VVC.

Methods: 20 women with six or more symptomatic attacks of VVC in the past year (at least four proved microbiologically). Clinical atopy determined by the International Study for Asthma and Allergies in Childhood (ISAAC) questionnaire assessed blindly. Monitoring by daily symptom diary and self taken vaginal swabs. Treatment with zafirlukast 20 mg twice daily for 24 weeks or until three microbiologically confirmed episodes of VVC. Response assessed by daily symptom diary and self taken vaginal swabs. Subjective response scales for improvement, side effects, and change in other allergic disease completed when stopping treatment. Semistructured telephone interview 1 year after stopping medication.

Results: 14 patients (70%) reported a subjective response on the improvement response scale. Six (30%) showed a complete response with no further symptomatic attacks of VVC or negative swabs when symptomatic. Seven (37%) remained symptom free 18 months after entering the study—that is, 12 months after stopping therapy. 11 (58%) remained symptom free for at least 3 months after stopping therapy. This does not include one patient who remained symptom free but continued on zafirlukast because of an improvement in her asthma. There was no clear relation between response and atopic status. Six of nine atopic subjective responders reported improvements in other allergic symptoms. Side effects were minimal; one seemed clearly attributable to the drug.

Conclusion: Zafirlukast offers a potential new treatment for recurrent VVC that requires confirmation in controlled studies.

Posted by Jacob Reider, MD at 01:32 AM | Permalink

From eCMAJ

Recommendations

• Given the balance of harms and benefits, the Canadian Task Force on Preventive Health Care recommends against the use of combined estrogen–progestin therapy and estrogen-only therapy for the primary prevention of chronic diseases in menopausal women (grade D recommendation).


• For women who wish to alleviate menopausal symptoms using hormone replacement therapy (HRT), a discussion between the woman and her physician about the potential benefits and risks of HRT is warranted.

This is a clear and compelling review of this complex topic. I must admit that I was never much a fan of HRT to begin with.

Posted by Jacob Reider, MD at 01:22 AM | Permalink

Posted by Jacob Reider, MD at 04:39 PM | Permalink

Craig's notes:  Family docs, pap smears, and cervical cancer risk opens up a compelling thought along the lines of my discussion the other day of prostate cancer screening:

"..The vast majority of the post-hysterectomy patients in my practice who were also seeing gynecologists or had previously seen gynecologists were still under the impression that they needed regular Pap smears."

He's right.  Like the PSA talk -- this one takes a long time, and inherently involves a discussion of risk.  Women who are post-hysterectomy are not without some risk ...but ... the real risk is quite low:

"The probability of an abnormal Papanicolaou smear in this group of women was 1.1 percent, and the positive predictive value of the Papanicolaou test for detecting vaginal cancer was 0 percent "

 yet ... like the free prostate screenings so commonly advertised in the local paper ... this may be better business than it is medicine.  ugh.

Posted by Jacob Reider, MD at 11:56 PM | Permalink | Comments (1)