Can I just take aspirin for my blood clot, instead of coumadin/warfarin ?

Patients are usually asked to take coumadin/ warfarin (blood thinner pills) for about 6 months after diagnosis of blood clot.  Coumadin or warfarin are vitamin K antagonists.  Thus, it is inconvenient since patients need to avoid certain green leafy vegetables, which contain vitamin K, in their diet.  In addition, they have to get their blood tested frequently to make sure that their blood is not too thin or too thick (INR test).

Some of my patients have asked if they could be switched to aspirin alone.  It would be a lot easier than taking warfarin.   In this month New England Journal, a study randomly assigned 822 patients who had completed initial anticoagulant therapy after a first episode of unprovoked venous thromboembolism (blood clot) to receive aspirin, at a dose of 100 mg daily, or placebo for up to 4 years.  The results showed aspirin, as compared with placebo, did not significantly reduce the rate of recurrence of venous thromboembolism but resulted in a significant reduction in the rate of major vascular events, with improved net clinical benefit.

Sorry, you still have to take the warfarin if you have blood clot but discuss this question with your physician.  Furthermore, there are newer pills that may be easier to take than warfarin.  FDA just approved Xarelto for blood clot but I expect this drug would cost a lot more than warfarin.

Reference:
Brighton TA, et al. Low dose aspirin fo recurrent thromboembolism.  NEJM. Nov 2012.

Should I take vitamin supplements?

Vitamins have done wonder in our medical history.  Vitamin D supplement has made Rickets a rare disease.  Folic acid intake by pregnant women have reduced the incidence of spina bifida in newborns.   These public health achievements led many of us thinking that if a little is good, then more is better.   Some have speculated that antioxidants such as beta-carotene, vitamins A, C and E, may protect human cells from premature degradation.  Thus, they may prevent or even cure cancers.  Not surprisingly, many of us jump into conclusion of taking multivitamins is good for our health.

However, the science of vitamins is not very clear.   The Women's health initiative study which followed 160,000 women for about 8 years showed that 42% of study subjects who took multivitamins suffered the same rates of cancers, heart attacks, and strokes as the study participants who did not take the multivitamins.  A trial showed concerning increased rate of lung cancer in patients who took beta-carotene and other supplements.  A randomized trial of 30,000 men was halted in 2008 when preliminary analysis of the study showed that selenium and Vit E supplements were increasing number of cancers.

From Uptodate, I found this statement: The US Preventive Services Task Force (USPSTF) clinical practice guideline provides several recommendations for vitamin supplementation and can be accessed through the website for the Agency for Healthcare Research and Quality at www.ahrq.gov/clinic/uspstfix.htm. The USPSTF recommends 400 to 800 micrograms/day Folic acid for all women planning of pregnancy. The USPSTF found insufficient evidence to recommend for or against the use of supplements of vitamins A, C, E, multivitamins with folate, or antioxidant combinations for the prevention of cancer or cardiovascular disease. The USPSTF also recommend against the use of beta carotene for the prevention of cancer or cardiovascular disease.

What shall we do?  My suggestion is we should follow the USDA's dietary guidelines: for most of us, our vitamins should come from our foods rather than vitamin supplements.  Our meals should consists of wide variety of fruits, vegetables and even some proteins (lean meat).  I usually tell my patients that their meals should have variety of colors and variation.  Foods are very complex with many undiscovered biologically active ingredients and we have evolved for many millions years adapting to them.  A few single vitamins, recently discovered, are too simple solution to meet our dietary needs. 

Reference:

- U.S. Preventive Services Task Force. Ann Intern Med. 2009;150(9):626

-Routine vitamin supplementation to prevent cancer and cardiovascular disease: recommendations and rationale.Ann Intern Med. 2003;139(1):51

- Uptodate. Vitamin supplementation.  November 2012

Genetic testing for ovarian cancer

About 10-15% of epithelial ovarian cancer are due to BRCA genes mutations.   Some of my patients with ovarian cancer are concerned that their daughters and sisters may also have an increased risks to develop ovarian cancer.   They are correct that first degree relatives (mother, sister, child) of an ovarian cancer patient would increase their baseline life time risk from 1.4% to around 2%.  If they have BRCA genes mutations, their life time risk jumps to about 50-85% for breast cancers and15 to 40 percent chance of developing ovarian cancer.

BRCA genes mutations are found more commonly in patients with a personal history of breast cancer and/or a family history of breast and ovarian cancer, especially if associated with young age of onset, multiple tumors, and involvement of male family members affected with breast cancer.  Ashkenazi Jews ethnicity is also a known risk factor.  Thus, if you have these histories, do talk to your physician about getting genetic counseling.  The genetic counselor will obtain more detail history and use a program to estimate your risk for BRCA genes mutations.  Genetic testing is usually recommended if your risk is estimated to be around 10% or higher.

Patients may have concerns of being discriminated after a genetic testing.  Fortunately, the Federal Genetic Information Nondiscrimination Act (GINA) of 2008 prohibits health insurers and employers from asking or using genetic test information in decisions about employment or insurance eligibility/coverage.
 
References:
- Pharoah PD, et al. Int J Cancer 1997; 71:800

- Hudson KL, et al. Keeping pace with the times--the Genetic Information Nondiscrimination Act of 2008.N Engl J Med. 2008;358(25):2661.

-Colditz G, et al. JAMA 1993; 270:338.

Does air cause my cancer to spread during surgery?

A few patients have concerns that when I operate to open their abdomen that air would make the cancer to spread.  Usually the story goes as "my grandmother went to surgery for cancer.  The surgeon opened her abdomen and closed.  Then she died a few days later because the cancer spread faster".  

I searched the literature and could not find the scientific basis for this.   However, the story may have a merit.  I could only speculate that the grandmother's cancer was too extensive that the surgeon decided to open, (may be biopsy), then closed the abdomen again.  She probably died from the extensive cancer or cancer complications (such as blood clot), but not from the air that entered her abdomen.

Cervical cancer without HPV

Most studies confirm that 99% of cervical cancer are due to Human Papilloma viruses.   However, there is a small minority of cervical cancer that is not HPV related.   Recently, I operated on a 17 year old girl who is completely HPV negative.   I reviewed the literature and found that the youngest patient with non-HPV related cervical cancer was a 6 year old girl!   The rare type is clear cell adenocarcinoma rather than the usual squamous cell carcinoma (Usually HPV related).

HPV that causing cervical cancer are almost always transmitted through sexual contact.  The HPV require skin abrasion/injuries to allow them to penetrate to deeper skin layer so they can reproduce.  Chronic HPV infection, especially with high risk types HPV 16 and 18, are usually required to cause cancer (exception is shorter period required in immunosuppressed patients such as HIV infected or transplant patients).  This is why sexual abstinence and condoms reduce the risk of HPV infection.  However, clear cell cervical cancers do not seem to require HPV or sexual intercourse to cause cancer.

HPV vaccines are effective in reducing the risks of HPV related cervical, vaginal, vulvar and anal cancers.  Some patients have asked me if they could get HPV infection from the vaccines.   This is very very unlikely since the vaccines do not contain HPV.  The vaccines have the shell-like virus coat without HPV DNA.  I don't know any case report in the world that showing HPV vaccines causing HPV infection/cancer.   I highly recommend HPV vaccines for girls and boys to reduce these risks. 

Disclaimer: I am a speaker and consultant to Merck which makes one of the HPV vaccines.  

Sex and cancer diagnosis

Many patients of mine have told me that their cancer diagnosis turned their sexual interest down significantly.  It is very understandable for a sexually active couple to stop after seeing their gyn oncologists since their energy is focused on this new challenging diagnosis.   Furthermore, chemotherapy and surgery just wear you out to even thinking about this issue.

However, as time passes, there are physical changes that may affect your sexual health in the long term.  You may hear me saying that if you don't use it you lose it.   Similarly, vagina is like any other organs.  If you don't use it, especially when you become menopause due to surgery/radiation, your vagina tissue becomes less elastic and its diameter will narrow.  Sex may cause more pain and discomfort than before.  Do talk to your doctor about this and don't be embarrassed since many patients have similar questions that you do.  One of my patients, Michelle Witlock,  is very knowledgable and open about her experience going thru the extensive cancer treatment and how it affected her sexual life.  She gave me permission to share her website with you.  Do consider visiting her sites for informative stories: 

http://www.tamikaandfriends.org/get-support/ask-our-experts/sex-after-cancer

http://www.michelleleewhitlock.com/index.php

New biomarkers and ovarian cancer

Most people are aware about CA125 by now.  It is a blood test that measure our antibody responses to cancer antigen and it is called 125 because it was the 125th antibody against the studied ovarian cancer cell line.   It is elevated in about 80% patients with advanced ovarian cancer as well in other cancers such as uterine, cervix and others.  Unfortunately, it is also increases with other non-cancer conditions such as endometriosis, infection, inflammation, etc.  Therefore, CA125 is FDA-indicated only to measure tumor responses to chemotherapy, not to screen for ovarian cancer.

Another relatively new biomarker is HE4 blood test.  It is more specific than CA125 in that HE4 is not as elevated as CA125 in patients with endometriosis.   HE4 is also only indicated for cancer monitoring, not as screening.

Ova1 is a blood test measuring 5 different proteins which is put into one score to help surgeons to triage patients as low or high risk for ovarian cancer.   FDA cleared its usage for patients who are about to be operated for ovarian mass.   If the Ova1 test is abnormal, the test would suggest that gyn oncologist should be involved in the surgery.  In contrast, if the Ova1 test is normal, then the patient is at low risk for ovarian cancer and no gyn oncologist is needed to be involved.   Disclaimer: West Clinic was involved in the clinical study leading to the FDA approval of this test.

ROMA is another blood test combining CA125 and HE4 into one score.  ROMA is also FDA-cleared to be used like Ova1. Both Ova1 and ROMA are not indicated for ovarian cancer screening.

By now you may ask why don't any of these biomarkers be used to screen for ovarian cancer.  Unfortunately, no present test is currently has enough sensitivity and specificity to screen for a low prevalence disease like ovarian cancer (prevalence is 1 out of 2500 American women = 0.04%).   Even when we have a test with 100% sensitivity and 99% specificity, we only get about 4.8% of positive predictive value.  This means that this ideal test will only identify correctly one patient with ovarian cancer but falsely diagnosed 20 other patients who have no cancer as having ovarian cancer.   It is indeed a holly grail to find a better screening test.

Reference:

-Ueland, FR, et al. Obstet Gynecol 2011:VOL 117, NO. 6, June 2011

-ROMA® (HE4 EIA + Architect CA125 II™) Instructions For Use 2011-09, Fujirebio Diagnostics, Inc  

-Bast RC, et al.  Differential diagnosis of a pelvic mass.   Int Gyn Cancer. 2012