Colin Kopes-Kerr, MD
6444 Timber Springs Drive
Santa Rosa CA 95409
E-mail: cpkerr@nni.com
Kopes-eticHealth.com:
A New Dawn for Health Care Information
For Patients & Consumers
It is the mission of this site to promote the exchange of ideas and information between providers and consumers, which is a never-ending task. We will start with an "Open Letter to Patients" to introduce Dr. Kopes-Kerr's new book, "How To Help Your Doctor," followed by serial installment of new chapters as they are written. If the spirit moves you to respond, please go to our Discussion Page to post your comments.
Want to Know What the Leading
Health Concerns for Your Age, Gender, Ethnic Group, and Region?
Visit the CDC's web page for the Leading Causes of Mortality
in the U.S.:
http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html
An Open Letter to Patients
Why Doctors
Need Your Help
Almost anyone who has ever been a patient
waiting in a physician’s office has direct reason to know that doctors need
help. Why is it a common experience routinely to have to wait for an hour or
more to see your doctor? The reason is because they can’t get it all done in
the time allowed. They can’t get what they think is important done, and often
they can’t get even what you think is important done. Why not?
There are two basic reasons. One of them has to do with you. Often you are
not prepared to make the most use of strategically important time with your
physician. Many patients either have a list of 4-7 things they want to talk
about (it is pretty routine to have at least 4 problems once you hit the age of
55 years), and doctors just don’t have enough moments in a 15-minute visit to
address so many issues. This is why it is absolutely critical that you be
prepared, have a specific agenda, and know your own priorities for that
15-minute interaction. This, of course, is what this book is about. I will help
you plan a very specific agenda for your physician for that 15-minute visit.
The other reason is that doctors generally are blindly trying to follow the
advice of various experts in determining how much attention to give each
problem. Doctors have an endless set of authorities to whom they defer to help
them make most of their basic decisions: how many pieces of data to ask you
about, how much of a physical examination to do on you, how many tests to order,
how many and which prescriptions to write for you, and how soon and how many
times to see you again after this visit. The problem is that they have to do
this for each of the problems you mention to them. Thus, even if they cut out
all the chit-chat (that makes your personal to you), they run out of time half
way through the second problem. If they chit-chat, then they barely get the
first problem taken care of. It is up to you to determine the appropriate level
of chit-chat; it is always a trade-off between getting specific agenda items
handled properly and being able to share bits of yourself with this fellow human
being. Sometimes absolutely the right thing to do is to just drop all
task-related agenda items and talk about your concerns–anxiety, depression,
sleeplessness, social embarrassment, difficulty with the kids or your spouse.
But this is a decision for you to make, not for your doctor.
In order to grasp the absolute need for you to take control of the agenda in
the doctor’s office, you need to understand the nature of the pressure he’s
under. Let me try to explain it this way.
You expect your doctor to be able to take care of your chronic health
problems–like asthma, high blood pressure, diabetes, heart disease, etc. Right?
If he doesn’t who else would? And you also expect her to advise and implement
preventive health measures that might be beneficial to you. Right? And,
finally, you probably have some specific concern, something not right, that
prompted you to schedule this particular visit–what physicians call your ‘chief
complaint.’ Here’s the dilemma, as presented in a few important studies over
recent years.
In a study reported in the Annals of Family Medicine in 2005, investigators
attempted to determine how much time it would take an average physician to care
for 10 of the most common chronic diseases he sees daily in his office if he
followed various expert guidelines published which define quality care for these
diseases. The striking answer produced by this study is that it would take 10.6
hours per day just to take care of this handful of common chronic diseases. This
answer was reached merely by adding up all the number of expert-recommended
visits, assuming a standard 15-minute visit, for these 10 problems in varying
degrees of control from stable to actively progressing or deteriorating.
To take just one example that I have substantial experience with, consider
the management of a patient with diabetes. In 1998 the American Diabetes
Association, the recognized expert in its field, published a “Standards of Care”
for the management of patients with diabetes. Their guideline recommended over
30 different, complex pieces of historical information be obtained for all
patients at the first visit, that a full physical and neurological exam be done,
that about a dozen laboratory test results be reviewed or ordered, and that
extensive patient education both about the disease and about their medications
be given. A reasonable estimate of the time to do this adequately would be 2
hours. Perhaps, some endocrinologists in private practice actually have 2 hours
of time to spend with a new diabetic patient, but no one I know in primary care,
where 90% of all diabetes care goes on, has ever had this amount of time. In
fact, in order to try to put a practical face on these recommendations, I
convened several focus groups of family physicians in southcentral Pennsylvania
(a rural area where primary care physicians do most of this work). When
describing their own experience these physicians reported that they were lucky
if they able to spend a half-hour with a new diabetic patient; they reported the
frequent experience of making this diagnosis incidentally in adults in the
middle of evaluation for another problem and trying to cover the basics in only
10 minutes. Diabetes is probably the most complicated disease that primary care
physicians management, and good care requires regular systematic coverage of
over a dozen issues. These physicians, at least as confided in my focus groups,
would love to have an authoritative guideline that was short, simple, and
focused on the critical aspects of care. That’s not what they get from the
experts. Instead they get a completely untested, impractical, overly elaborate
set of recommendations that simply have no place in the real world. (In fact,
even at the time of this writing there has never been any study that showed
either that even specialists used these guidelines or that anyone was able to
achieve better outcomes by using them.) In this book, I will tell you exactly
what you need to know to take superb care of your diabetes. It’s very doable,
and it’s very important. Few diseases do as much damage as diabetes does, if it
is not managed well.
In a similar study by some of the same authors in the American Journal of
Public Health in 2003, they analyzed how much time it would take general
physicians to comply with standard preventive medicine guidelines. In an effort
to make the task more manageable, they decided just to look at the top half of
more than 169 different potential preventive interventions–the ones that had the
best scientific evidence to support their benefit. What the investigators did
was to perform essentially a time-motion study in physician offices recording
the actual amount of time spent doing the recommended interventions. The
surprising result here is that they determined that it would take 7.4 hours per
day just to carry out the top 50% of all recommended interventions.
Thus, it will take your doctor 18 hours a day to handle the minimum expected
medical standard of care. Mind you, this is without considering whatever amount
of time it will take to address your ‘chief complaint,’ typically a cold, or
bladder infection, or muscle sprain.
The bottom line is that there is no way it is all going to get done. This is
the fact of modern medicine. It presents a dilemma for every one. Doctors become
disillusioned and frustrated by their inability ever to get it all done and by
the perpetual experience of having to accept so much less accomplishment than
they aspire to. Patients are continually frustrated (and occasionally sue)
because a lot of very important issues never get adequately addressed. The
health care system (if it can be called that) in the U.S. just tolerates this
grossly inadequate status quo. According to one expert in the August 2006 New
England Journal of medicine, there is no major impetus on the current horizon to
address this issue.
This is the very problem that this web site will help to solve. Without a
gargantuan effort by scientists, academicians, and politicians, nothing else
will solve this problem for you. This, of course, will take years. The best
recent example of a health care project of similar magnitude was the fate of
President Clinton’s proposal for national health insurance, and you remember
what came of that. So you have got to do it. There are two basic means of
insuring your own health–what you do for yourself and what you do with your
doctor. This site will discuss both of them. What you can and should do for
yourself without your doctor, however, is quite simple–really no more
complicated than 30 minutes of exercise daily, 5 servings of fruits and
vegetables daily, and avoiding obviously toxic substances like cigarettes,
excessive alcohol, and illicit or excessive prescribed drugs. The major focus of
www.Kopes-eticHealth.com will be very specific details of what
you need to know and need to ask your physician to do for you in the context of
your specific health care needs or preferences.
The other exciting and reassuring result of modern medical research is the
information that many chronic diseases, like diabetes for example, are much
better managed with more favorable results when patients take over management of
their own care rather than when physicians do it. This is a very important piece
of new research information which we need to try to understand. There is already
some supporting evidence to demonstrate that, if you take charge of your own
care, as I suggest, you will achieve substantially better results. We will look
at some of this research in detail.
To give an example of how your role begins, you can start with the
unmanageable list of 169 potential interventions covered by the leading
authority in this country–the U.S. Preventive Services Task Force. Fortunately,
only a very few of these will apply to you. So all you have to do is to
prescreen the list and, based on your age, gender, and situation, you can pick
the handful that apply. I will give you some specific guidance on the ones that
have the highest value to insure that you limit your list to a feasible number.
Remember, you are only selecting your highest priorities, because there is only
time to do so much in a visit. (It is a perfectly valid strategy to schedule a
follow-up visit specifically to include more of these preventive services, but
don’t try to get too many into a single visit. That’s just frustration for
everyone.)
The second job for you is both easier and more difficult–dealing with any
chronic health problems. It is easier because you know what health problems you
have, and you just don’t have to bother with any others (and, in general, don’t
let your doctor go off on tangents and screen you for diseases you’re not
concerned about them; because of certain biases built into the healthcare
system, they tend to feel better when they do this. Stay focused.). It is harder
because you have to master a small amount of very specific information that will
give you a handle on your own disease. For example, if you have high blood
pressure, it’s worth knowing that family history is not important (i.e., don’t
waste time on it); the most important part of the general history is to review
the complete set of heart disease risk factors (age, gender, smoking status,
high blood pressure, diabetes, no exercise, metabolic syndrome, cholesterol, and
renal impairment, and family history of heart disease [not hypertension]). The
physical exam (except for the measurement of blood pressure) is unimportant (so
don’t waste time on it; the experts love to have your doctor do time-consuming,
useless, and awkward things like looking into your eyeballs with a light,
listening to your heart, etc.). Treatment is simple–all patients should start
first with a thiazide diuretic like hydrochlorothiazide (HCTZ) and second with a
drug called an ACE-inhibitor (like Vasotec, Lisinopril, Accupril, Benazepril,
etc.; and it doesn’t matter which one; just go for the best price in your
drugstore–you have to ask your pharmacist; your doctor will usually not know
[prices change so fact, and he has just got so much else to keep up with]. The
goal of treatment is to keep your blood pressure below 140 mm Hg over 90 mm Hg
(< 140/90 mm Hg), and measurement at home or at your pharmacy or supermarket is
generally more reliable than measurements in your doctor’s office (mainly
because we all tend to get tense in the doctor’s office; if you follow the
recommendations in this book, you should be able to feel a lot less tense too!).
If your blood pressure is below that level, it is enough to come in for a
check-up and medication refill every 3-6 months; if it is not, you should plan
more frequent visits, medication adjustments, and lifestyle adjustments
involving diet and exercise. You can see to it that your blood pressure is and
remains below 140/90 mm Hg.
While the discussion above addresses the meat of the issue there are a
couple of general administration points to take up, especially if you have not
already discussed them with your doctor. These are explicit decisions of the
locus of decision-making and the issue of using placebos.
Most of us were raised in the traditional model of medical decision-making
where the doctor got your story and recommended what was best for you and you
just followed hopefully. This model has the physician in control of
decision-making. The premises of this book explicitly reject that model for the
sake of both parties. But the decision is yours to make. There are several
different potential levels of involvement in medical decision-making:
(1) physician in control, assesses the data, prescribes the treatment plan
(2) physician recognized as informed authority, and his ‘advice’ is given
higher weight than the patient’s own information
(3) patient recognized as the leading expert on his or her own body, and
that expertise is valued as equal to the physician’s expertise in medical
diagnosis and therapy, resulting in a joint or consensus approach to management
(4) the patient is the customer and is therefore always right. The customer
has a right to choose the service and level of testing and treatment within
acceptable limits of physician ethical behavior. The physician’s role is mainly
permissive with some advisory capacity.
There are an infinite number of variations of this model that can also be
created, but these 4 basic styles capture the essence of most. You merely need
to spend a few moments in advance pondering these alternatives, so that you can
negotiate the specific level of service desired with your physician. Of course,
not all physicians will be comfortable with models that have patients in
control, but this is OK. It merely means that this particular physician is not
for you. There certainly are physicians out there who are flexible and able to
respect whatever expertise you bring to the exam table. The problem with so much
of conventional medical practice is that a formal discussion of these options
never occurs, and the doctor-patient relationship limps uncomfortably from one
style to another. If you are clear about what you want, you can get it. In fact,
this is the only way you can get it. If you’re visiting
www.Kopes-eticHealth.com, you probably have an interest in being a very
active participant in this process and that’s healthy!
Self-Assessment of Cancer Risks
Cancer is a concern to everyone. This is
especially true if someone in your family or among your close friends has had
cancer. The general risk of developing cancer in the US is about 0.4% per year.
For the most part interventions against cancer and various attempts to prevent
the different kinds have had only equivocal effectiveness. This is an area in
which it is particularly important to be an informed consumer. Essential in
order to do anything intelligent to mitigate your personal cancer risk is to
systematically appraise your personal situation and determine what factors may
put you at increased risk for specific cancers.
A wonderfully practical article on this topic appeared in the
British Medical Journal.1
There Janusz Jankowski and Emma Boulton presented a systematic approach to
assessing personal cancer risk with respect to a variety of cancers using an
alphabet-based memory aid--ABCDEFGHIJK.
The point is, unless you are at specifically increased risk of developing a
specific cancer, there is little point in aggressive general cancer screening
technology.
Their article lists
A to
K
of factors associated with an increased risk of cancer at specific sites:
Alcohol
consumption > 3 units a day: predisposes to squamous cancers, especially
cancer of the bladder and esophagus.
Body
Mass Index > 25 and certainly > 30: predisposes to all solid cancers. If
you don’t know your BMI, see the free calculator at:
http://www.nhlbisupport.com/bmi/
.
Cigarette
smoking at any level (even passive smoking): predisposes to bladder
cancer, lung cancer, head and neck cancer, esophageal cancer, and oropharyngeal
cancers.
Diet,
especially one that is high in fat: predisposes to all solid cancers.
Exercising
< 30 minutes a day: predisposes to all solid cancers.
Family
history of cancer: (in at least one first degree relative (e.g.,
brother, sister, mother, father, son, daughter) and at least 3 people in two or
more generations): predisposes to inherited cancer syndromes, including breast
cancer, colorectal cancer, diffuse gastric cancer, ovarian cancer, prostate
cancer, and uterine cancer.
Genital
health (sexually transmitted infections): predisposes to cervical cancer
and penile cancer.
Health
promoting drugs that may decrease global cancer risks (but need a
careful risk benefit analysis): colonic adenomas can be treated with los dose
aspirin but can have serious side effects; hormone replacement therapy is linked
with breast cancer)
Intense
sunburn: predisposes to melanoma.
Job
related factors: lung cancer (exposure to asbestos and particulates), skin
cancer (contact with arsenic)
Known
disease associations: colorectal cancer has predisposing mucosal
pathology–adenomas, celiac disease, ulcerative colitis.
The actions they recommend for physicians at the time of a
routine check-up are:
1. Review history for any symptoms of cancers of concern (e.g. bleeding in the
rectum, altered
bowel habits, weight loss)
2. Educate the patient that early investigator of cancer symptoms increases the
chances of cancer
being successfully treated, but that most of such symptoms
are not in fact due to cancer.
3. Emphasize the importance of a good diet. A patient should eat at least 5
portions of fruit and
vegetables each day and cut down on fat, salt, and added
sugar.
4. Explain that many cancers are preventable through lifestyle modification.
Help the patient
strategize as to what modification to tackle first–smoking,
exercise, dietary modification, or
alcohol consumption.
5. If the patient is serious about lifestyle modification, counsel about the
advantages and options of
various support methods for assisting behavioral change.
6. Offer objective advice about the risks of medical interventions such as
x-rays, Pap smears,
endoscopic examinations (sigmoidoscopy, colonoscopy,
endoscopic esophagoscopy, gastroscopy
and duodenoscopy (EGAD)), mammography, Pap smears and
additional interventions
(e.g. ThinPrep, HPV testing), and fecal occult blood testing
(FOBT). The authors state, “Most
people asking about the risk of cancer won’t develop it, and
in about 10% of people
anxiety levels will be raised needlessly.”
7. Provide as much objective (non-cancer society and non-specialty society
sponsored) information
and web-links as appropriate.
[1. Jankowski J, Boulton E. 10-Minute
Consultation: Cancer Prevention. British Medical Journal 2005; 331: 618]
The following are my own comments on the most common cancer
screening programs:
Lung cancer: Prevention is simple. Don't smoke. If
you do smoke, quit. If you're a former smoker who has quit, it may make sense to
use CT-scanning technology for periodic attempts at early detection of lung
cancer. The general population risk for lung cancer is 50 per 100,000 for women,
and 80 per 100,000 for men, and this is concentrated among smokers. (SEER data,
2003) The risk among male non-smokers (at least in Sweden) is about 4 per
100,000 persons.
Breast cancer: The overall risk for adult women is
120/100,000 (2003 data) or about 3% per decade after age 40 for average risk
women. A physician breast exam coupled with routine periodic mammography have
been the standard ways to try detect such cancers early. (Note neither of these
methods actually prevent breast cancer, but they do help prevent deaths from
breast cancer.) The studies show that breast cancer (specific) mortality can be
reduced by about 33%. The problem is that there has been no reduction in
all-cause mortality from these methods. The screening program is both time
intensive and costly. It takes at least 20 mammograms between the ages of 40 and
70 to confer the full benefits of the program. The problem is that each time a
mammogram is done, there is a 2% chance of finding a 'suspicious' abnormality
for which biopsy is recommended. Over 90% of these are benign, but there is no
way to tell without biopsy. Thus, women seeking this type of screening should be
aware that the odds of finding a 'suspicious' lesion significantly exceeds the
likely of finding a true cancer. In general, it appears that the only women who
sign up for the full screening program are those with very good health
insurance, and even this group rarely received the full 20 recommended
mammograms.
Colon cancer: The overall risk of colon cancer is
43 per 100,000 for women, and 58 per 100,000 for men. (2003 data). Physicians
are also able to reduce your risk of dying of colon cancer by about 33% with
some combination of testing your stool for microscopic amounts of blood (fecal
occult blood testing, or FOBT) and either sigmoidoscopy or colonoscopy. It is
recommended that this begin routinely for all adults at age 50 and be repeated
at some poorly defined regular interval thereafter. One of the major problems
with this recommendation is that there are not enough physicians in the U.S. who
are skilled at sigmoidoscopy/colonoscopy to carry out the recommended screening.
Another major problem is that the expert group in the U.S. (the U.S. Preventive
Services Task Force, USPSTF) is unable to clearly identify which method of
screening is best. (Just to go on the record, my recommendation, limited to
those who have a specific reason to proceed with such screening, is to have
colonoscopy done every 10 years, and feel free to quit the program at any time
in the middle.) As with breast cancer screening, there are significant risks of
identifying false positive test results. The fecal occult blood test is
estimated to be falsely positive between 2-10% of the time. Any abnormal results
is considered an indication for full colonoscopy. To put this 2-10% risk of a
false positive in perspective, it should be compared to a risk of 56 out of
100,000 persons for a typical man at age 50. Finally, colon cancer screening
also has failed to demonstrate any evidence of a reduction in all-cause
mortality. These tests are primarily of benefit for those who clearly have an
increased risk of colon cancer–such as those with chronic inflammatory bowel
disease, familial polyposis, or a family history of colon cancer.
What none of the various expert groups tell you is that there
are other, less invasive, alternatives to putting some foreign object up your
rectum. A report in JAMA4 from the very large Nurses' Health Survey study, found
that women who had been taking supplemental folic acid
(1 mg or more) daily for 10 years had their risk of colon cancer reduced by 66%.
(This is twice the benefit of the popularly supported approaches to colon cancer
screening; the only downside is that it doesn't make as much money for those
specialists who do the examination inside your colon.) In addition it is clear
that various other factors offer a substantial reduction in risk. These include
exercise, low-dose aspirin, calcium supplementation, and general B-vitamins
(particularly B6 and B12). Alcohol and smoking will both increase your risk. It
really is illogical to undergo elaborate screening for this condition if you are
going to continue to smoke or use excessive alcohol. Finally, the Mediterranean
diet, as noted above, can reduce all-cause mortality from this and other cancers
by 50-60%–a bargain that's hard to beat.
The truth is that most individuals in the U.S. (>50%) have
passed on traditional colon cancer screening; it simply is not a popular test
even after Katie Kouric had her colonoscopy on national TV. This appears to be
appropriate. Among the available methods, the traditional barium enema and
flexible fiber endoscopes are my last choice for this task.
Cervical cancer: Cervical cancer has long been one
of the leading causes of cancer in women, but it is actually fairly rare,
occurring in only 7.5 adult women per 100,000 (2003 data). The Pap smear has
long been the primary methodology for screening, but this has now been augmented
by the application of routine testing for traces of certain types of human
papilloma virus, which are associated with an increased risk. The problem with
these enhanced techniques, however, is that they dramatically increase the risk
of minor abnormalities (such as low-grade neoplasia [LSIL] or atypical squamous
cells of undetermined significance [ASCUS], which end up triggering an extensive
evaluation (i.e. biopsy) without any clear benefits. These techniques also fail
to effect any reduction in the most important outcome–all-cause mortality.
Prostate cancer: The overall risk for men is
150/100,000 (2003 data). There are two things you should know about prostate
cancer:
(1) Fortunately, women don't have to
worry about this one;
(2) No major health advocacy
organizations endorse or recommend routine prostate cancer screening except from
the two who stand to profit from it. It is still recommended by the American
Urological Association since the urologists make a lot of money from doing all
the prostate biopsies that are recommended after initial screening. The American
Cancer Society also recommends screening but that is because they are simply
committed to raising funds to fight all cancers, and not because there is any
promising evidence that screening techniques for this one work. The reality is
that over 50% of all men have some small amount of cancerous cells in their
prostate when they die. For the overwhelming majority of them (> 90%), these
cancerous cells never caused any discomfort or dysfunction and will have nothing
whatsoever to do with their death. For the greatest majority of men prostate
cancer is just an incidental finding at the time of death. This makes it very
questionable whether any screening technique is worth the trouble.
The other major problem with prostate cancer screening have
to do with the following recent findings from medical studies:
In 3 major trials following patients with prostate, cancer
for 10 years or more, patients who received no specific treatment did as well as
those who had aggressive treatment including radical prostatectomy or radiation
therapy. Over the last 10 years of aggressive screening using the PSA blood
test, the majority of all the easy-to-detect cancers have already been found.
Thus currently when the PSA test comes back elevated (abnormal) it is much more
likely to indicate mere enlargement of the prostate (which is non-cancerous)
that it is to indicate prostate cancer.
Skin cancer and melanoma: These are very
preventable. All of them are mostly related to sun and UV radiation exposure,
which you can control. There are two basic types, pigmented skin cancer
(melanoma), which is a bad disease, but easier to detect since it is dark and
changes rapidly, and non-pigmented skin cancer–mostly basal cell carcinoma,
squamous cell carcinoma, and its putative precursor actinic keratosis. These
later conditions are fairly slow growing and present as non-healing bumps or
prominent tiny patches of blood vessels on the exposed parts of the
body–particularly, the face and back of the hands and forearms.
Melanoma: The problem with screening for melanoma is
that there is a very common condition in 5-15% of the population called
'dysplastic nevi' (See Fig. 1), which can be awfully difficult, even for
physicians (both your family doctor and even your dermatologist), to distinguish
from melanoma.
Fig. 1: A Dysplastic Nevus
The result of this fact is that many of these benign dysplastic nevi end up getting biopsied, which doesn't really harm anyone, but does represent a fair amount of unnecessary dermatological procedures. The simplest, most practical advice I can give you for taking charge of this risk management yourself is (particularly in our current digital camera age) is to take, right now, a digital picture of any pigmented moles you or any member of your family have and repeat them once a year on this same date. If you see significant change in size between one year and the next, then get a second opinion from your physician (and bring in or e-mail your photos). Any lesion that changes rapidly in size, texture, or pigment over a few months should be looked at by your doctor sooner.
Physicians use a simple
ABCDE
memory aid (mnemonic) to help them separate the bad lesions from the benign
ones. These letters stand for:
A=Asymmetry:
Is the lesion growing asymmetrically? Most of the benign lesions tend to grow
more or less at the same rate out from the center, whereas malignant lesions
tend to be more lopsided and irregular.
B=Borders: Is the border of the lesion smooth and clearly outlined? Benign moles, even if pigmented, tend to be small round, raised, smooth bumps on the skin. One of the problems with dysplastic nevi, which are benign, is that their borders tend to be both irregular and poorly defined as in the picture above.
C=Color
& Contour: As illustrated above in the dysplastic nevus, lack of smooth,
even shading to the pigment is a concern. Lesions that are all of the same color
are more likely to be benign. Then ask, Is the lesion flat or raised? Is it
smooth or rough in texture. The smoother the texture is, the more likely it is
to be benign.
D=Diameter.
What is the size of the lesion across. Any lesion that is greater than one-half
or 6/10ths of a centimeter has a greater chance of being malignant, but many
dysplastic nevi grow to this size, so taking your own photo is still your best
bet.
E=Evolving
rapidly. The single most important warning sign of skin cancer is any
lesion with pigment that changes noticeably within a period as short as one
month. Have all of these checked by your doctor. If you have a before and after
digital photo, this will be of great assistance to him/her.
In recent years there has been a lot of public and
professional attention given to large scale publicity campaigns to avoid sun
exposure and to use sun screens rapidly. What you should know is that, despite
the intensity of the effort, we have absolutely no results yet that show that
sunscreens prevent skin cancer. It theoretically makes sense (even if it is a
great bother), but, in fact, it may not work. We certainly, as yet, cannot prove
that it does. There are even some data that suggest that people who use
sunscreens actually receive more overall sun exposure than average (because they
are often using it in anticipation of a long, relaxed day in the sun). For
myself, I believe that sunshine is good for both the body and the spirit (and is
the best way of treating or avoiding a serious, common form of depression known
as Seasonal Affective Disorder). You just have to use common sense. Don't get a
significant burn. If you ease up to it slowly, you should be able to get a
satisfying tan without having a major effect on your risk for skin cancer.
Furthermore, there is some evidence that the effectiveness of sun screens may be
increasing the incidence of some internal cancer that appear to be affected in a
positive way to sunshine exposure. You've got to use common sense on this. You
don't particularly need your doctor's help in this area unless you've got some
mark or bump on your skin that is changing rapidly.
The Secrets of Health
This is the simple way to understand the potential combined benefits of a healthy lifestyle when added to regular intake of some simple, safe, preventive medications.
* * *
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free DVD per family.
Order Online: Get the electronic order form to request your free copy of the DVD for children and their families at:
http://gold.ahrq.gov/eorders/order_page4907.cfm
Order by Phone: Call the AHRQ Publications Clearinghouse at 1-800-358-9295 to order Max's Magical Delivery: Fit for Kids (Product No. 04-0088-DVD).
Also Recommended
How's Your Health -- The Book [click on link to download 167 page book; or order on the site for $7.00]
Compare Your Health to Other Real People
...and it's free...!
Also Recommended
Learn the inside story of what makes doctors and patients tick. Read true stories from the art and practice of medicine. Visit "Pulse".
