When I was a very little girl, I was sitting at the kitchen table eating mashed potatoes, and my mother turned to our neighbor, who was visiting at the time, and said, “She’d eat mashed potatoes till the cows came home”.

I’d say that still holds true.

Except sometimes I eat my mashed potatoes in a soup.

This is an exceedingly simple soup that is  lighter in calories than mashed potatoes, but just as satisfying for this half Irish girl who is still wondering where she’ll put those cows if they ever show up on her doorstep.

Postato Leek Soup

This recipe is from Richard Olney’s cookbook Simple French Food,  via one of my new favorite blogs, A Serious Bunburyist. There is no cream in this – it does not need it. But that butter at the end? C-est manifique!

Ingredients

• 2 quarts salted boiling water
• 1 pound potatoes, peeled, quartered lengthwise, sliced (we used Yukon golds)
• 1 pound leeks, tough green parts removed, cleaned, finely sliced
• 3 tablespoons unsalted butter
• salt and pepper to taste

Instructions

Olney has you add the vegetables to the salted boiling water and cook till the potatoes are soft and mashable. I was dying to saute those leeks up first in the butter and then add the water (or maybe chicken stock) and the potatoes, and then maybe a bouquet garni, but I really had no say in the matter as I was still at work when Mr TBTAM started cooking. By the time I arrived home, the leeks and potatoes were done,  so I just got out the old immersion blender and went to town.  Maybe someday I’ll try a fancier version, but this was pretty close to perfect as far as I’m concerned.

Serve hot or cold with a generous sprinkling of sea salt and pepper to finish.

Brilliant societal analysis from Dawn Powell (1896-1965).

What most people wanted was the happiness of having what other people wanted. Then they had brief moments of an inferior happiness when they only got what they themselves but nobody else wanted. This rather spoiled things.  Some people made mistakes in their opinion of what other people wanted, but if they didn’t  find out they managed to be happy , maybe wondering a little once in awhile what everybody wanted this for.  Others wasted so much time trying to have what other people wanted that they never knew they were perfectly happy without it. The biggest jolt in growing up was to discover that that you    didn’t like what others liked and they thought you were crazy to like what you liked.

I’d never heard of Powell till my book club read her book “My Home is Far Away“, from which this quote comes. (Thanks, Stacy, for suggesting it.) This is pretty much par for the course for Powell, who never gained the prominence many think she deserved during her lifetime, for as Gore Vidal wrote  -

For decades Dawn Powell was always just on the verge of ceasing to be a cult and becoming a major religion.

Powell was born in Mt. Gilead, Ohio in 1896, but ran away from home at age 13 and lived most of her adult life in Greenwich Village, where she was part of the Bohemian scene that included EE Cummings and John Dos Passos. She published 16 novels, nine plays and numerous short stories, not a few of which were acerbic Manhattan-based comedies that have been called funnier than Dorothy Parker’s and virtually all of which were out of print when she died in 1965.  Powell was rescued posthumously from obscurity by Vidal and then music critic Tim Rice, who published her bio in 1998 but failed to sell her diaries in 2012 (although Columbia University eventually purchased them in March of this year). According to the Library of America, more of Powell’s books are now in publication than at any time in her life.

I plan on reading more.
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More on Dawn Powell

• Salon.com - How Dawn Powell Can Save Your Life
• Dawn Powell - Library of America Website on the author
• The New Yorker – Dawn Powells Masterful Gossip – Why Won’t it Sell?
• Good Reads – Dawn Powell quotes
• Gore Vidal – Dawn Powell, the American Writer

Pic – Dawn Powell, 1914. From Wikipedia

Looking for something to do tomorrow (Wednesday May 22) evening? Come hear the Weill Cornell Music in Medicine Orchestra and Chorus perform an all Schubert Program at the Caspary Auditorium (that funky blue dome on the Rockefeller University campus).

I’ll be singing in the soprano section.

Then I realized something was missing in her piece; something that should have been printed in big black letters:

NOTE: This story is not relevant to more than 99% of American women.

Why preventive mastectomy may make sense for Angelina, but not for you.

A must read.

In a beautifully written editorial in the NY Times entitled “My Medical Choice” Anjelina Jolie has come out publicly as a carrier of the BRCA 1 gene, which places her at high risk for both breast and ovarian cancer.  She has undergone a prophylactic nipple-sparing mastectomy with plans for future removal of her ovaries to prevent ovarian cancer.

I choose not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. It is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.  Life comes with many challenges. The ones that should not scare us are the ones we can take on and take control of.

Kudos to Jolie for choosing to tell her story in such a measured and informative manner. Having referred dozens of high risk women for BRCA testing, only to see them avoid it year after year, I for one  hope that Jolie’s story will encourage women at high risk to get screened.

But I also recognize that not every woman with a suggestive family history wants to know her BRCA status.

And that, too, is a choice.

What Most of You Need to Know

For the overwhelming majority of the rest of the women I see, and for almost  all of you reading this, the most important thing you need to know is buried within Jolie’s  editorial, and it is this -

Only a fraction of breast cancers result from an inherited gene mutation.

About 2% of women have a family history that suggests the possibility of BRCA mutation,  and only about 1/10  of one percent of women carry a BRCA gene mutation.

Thus, Jolie’s story, while compelling, is medically irrelevant to almost all women. But for a very few, it may be lifesaving.

Should you consider BRCA testing?

Not unless you yourself have had pre-menopausal breast cancer or have had ovarian cancer, or  have a strong family history of breast/ovarian cancer.  From the NCI, here are the recommendations for screening based on family history -

For women who are not of Ashkenazi Jewish descent:

• two first-degree relatives (mother, daughter, or sister) diagnosed with breast cancer, one of whom was diagnosed at age 50 or younger;
• three or more first-degree or second-degree (grandmother or aunt) relatives diagnosed with breast cancer regardless of their age at diagnosis;
• a combination of first- and second-degree relatives diagnosed with breast cancer and ovarian cancer (one cancer type per person);
• a first-degree relative with cancer diagnosed in both breasts (bilateral breast cancer);
• a combination of two or more first- or second-degree relatives diagnosed with ovarian cancer regardless of age at diagnosis;
• a first- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis; and
• breast cancer diagnosed in a male relative.

For women of Ashkenazi Jewish descent:

• any first-degree relative diagnosed with breast or ovarian cancer; and
• two second-degree relatives on the same side of the family diagnosed with breast or ovarian cancer.

What about prophylactic Mastectomy?

Mastectomy was not Angelina’s only choice.  Mastectomy is effective at reducing the risk for  breast cancer, but breast cancer mortality is not impacted due the effects of aggressive screening and excellent treatments for breast cancer when it is diagnosed in BRCA carriers who choose not to have a mastectomy on a preventive basis.  Thus, Jolie  could have opted for aggressive screening with breast mri and/or use of medication (tamoxifen or raloxifene) to cut her risk of breast cancer in half. But with the option for nipple sparing surgery, mastectomy appears less a barbaric operation than in the past, with only a small increase in risk for leaving the nipple behind.

The use of mastectomy is increasing, not just among BRCA carriers, but among women with early breast cancer or pre-invasive disease (DCIS and LCIS) that places them at higher risk for invasive cancer in the future.  I for one worry that mastectomy may be getting over-used, and hope that Angelina’s story will not result in more women having surgery than is necessary.

What about Ovarian Cancer Protection?

As a gynecologist, I’m particularly concerned about ovarian cancer in BRCA carriers.

Angelina’s decision to remove her ovaries and fallopian tubes offers her the best odds of avoiding ovarian cancer, the disease that took her mother’s life.  Unlike mastectomy, which prevents cancer but does not reduce mortality, oophorectomy does reduce mortality form ovarian cancer.  Because the truth is, we have nothing to offer to women to effectively screen and diagnose ovarian cancer at early stages  (although we offer it, ultrasound is not effective screening on a population basis), and treatments are just not as good as what we have for breast cancer.  So BRCA carriers are offered prophylactic BSO in their 40′s or once childbearing is completed.  The procedure itself can often be done as an outpatient  laparoscopic surgery.

We are beginning to understand that ovarian cancer may actually originate in the fallopian tubes. Research is underway to determine if removal of the fallopian tubes alone might provide similar protection as removing of both the ovaries and tubes.  It’s too soon to say how that will play out, but we are hopeful.

What most women do not realize is that we do have prevention for ovarian cancer.  It’s called the Birth Control Pill, and taking it can lower the risk for ovarian cancer by 80%.

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More reading

• CNN – What Angelina Forgot to Mention.  A Must Read.
• NYTimes - an excellent discussion on the rising use of mastectomy for breast cancer prevention
• NPR Blog - Peggy Orenstein raises concerns about women generalizing Jolie’s experience to the average woman not at increased breast cancer risk.
• LA Times - Anna Gorman, another BRCA carrier, tells her story
• Prophylactic Oophorectomy in BRCA Carriers
• Huffington Post - Good Video segment including interviews with breast experts and survivors.

Ms Jolie’s image used with permission from Wikipedia, Source: George Biard

We just had our final rehearsal last night with the orchestra – so much fun!  I’m really excited to be singing this wonderful music with my dear friends and fellow members of the Collegiate Singers. Two of the pieces are in praise of music and of St Cecelia, the patron saint of musicians and singers. The rest are marvelous English Glees.  The orchestration includes gorgeous cello, flute and oboe solos, and our solo singers are truly wonderful.   If you’re looking for a lovely way to spend a spring evening, do join us tomorrow, May 15 at 7:30 pm at the Church of Christ and St Stephens, a  little gem of a venue with great acoustics on W 69th st just east of Broadway.

Mississippi Sunrise in NOLA

It’s fitting that this year’s ACOG meeting was held in New Orleans, because navigating the 2013 ASCCP Pap Smear Management Guidelines presented there feels like trying to make my way through the Mississippi bayou. The guidelines include 18 different algorithms encompassing almost any combination of pap and HPV abnormality we docs are likely to encounter among our patients.  But all tributaries lead to the same place, where we achieve optimal reduction in cervical cancer with minimal harm.  

Cervical cancer prevention is a process with benefits and harms. Risk cannot be reduced to zero with currently available strategies, and attempts to achieve zero risk may result in unbalanced harms, including over treatment. …optimal prevention strategies should identify those HPV-related abnormalities likely to progress to invasive cancers while avoiding destructive treatment of abnormalities not destined to become cancerous. Adopted management strategies provide what participants considered an acceptable level of risk of failing to detect high-grade neoplasia or cancer in a given clinical situation.

I’m not even going to try to spell out everything in the guidelines, which come from the American Society of Colposcopy and Cervical Pathology (ASCCP), except to say that they represent further movement away from aggressive screening and treatment of pap smear abnormalities, especially in younger women, in whom treatment carries small but real childbearing risks. The guidelines are increasingly reliant upon HPV testing to determine who and how often to screen, and when to treat.  They also acknowledge the role of testing for HPV 16 and 18 as a way to be sure that those women with adenocarcinoma of the cervix (which is less likely to show up as cancer on a pap smear) are identified and treated. From the guidelines -

What should you expect?

• Less pap smears, for sure. Women should start screening at 21 and have paps every 3 years until age 65 (assuming, of course, that her paps remain normal).  There is no place for HPV as routine screening in women under age 30, as most of these women will acquire HPV one or more times by that age, with little consequence.  HPV testing is used in this age group to manage abnormal paps and to follow those with prior pap abnormalities, but that’s it.  Women age 30 and over have the option of pap with HPV co-testing – if both are normal/negative, she may go up to 5 years before her next pap.
• Little treatment of CIN1. CIN 1 represents HPV infection but is not a true pre-cancer and usually will resolve within two years. (If it does not resolve by then, treatment is an option.)
• Less use of colposcopy in younger women with mildly abnormal paps, even if HPV testing is positive. In women ages 21-24, one may repeat the pap with HPV testing at 12 months rather than go to immediate colposcopy for mild pap smear abnormalities (ASCUS and LGSIL).
• Continued decline in treatment for CIN2. Most CIN2 will resolve without treatment. (I’ve been backing off on cin2 treatment for some time now in younger women and indeed most lesions resolve.)
• The option to observe CIN3. I don’t know how often any of us are going to use that option, though I admit to having already taken it occasionally in younger women with focal CIN3 lesions that were removed at colposcopy.
• Increased interval pap followup in women who have had colposcopy or treatment for CIN2-3.
• Increasing use of HPV 16/18 testing to identify those women with mild pap abnormalities who may need immediate colposcopy.

Confused? There’s an App for that! 

In a very smart move, ASCCP has launched an app for providers wondering just what to do with those abnormal pap results. It’s called ASCCP Mobile, it costs $9.99 and it’s really cool.  Let me show you how it works-

Let’s say you have a 27 yo, non-pregnant patient with an LSIL Pap and HPV+. Just enter the info, click next  and, as Emeril would say – Bam! You’ve got the appropriate algorithm for her right there on your screen!

 Click next steps, and enter her colpo result, which let’s say was CIN3 and Bam!  You are advised to treat her, and to perform 12 month pap/HPV co-testing for follow up.

Of course, you could have pulled out the guidelines and found the right algorithm there, but this is a lot more fun.

ASCCP Mobile is not so much a recipe for patient management as it is a navigator through a complex algorithm that requires a lot more than just tapping a screen to understand and execute. I encourage you to read the actual guidelines article (links below), which provides the background and summarizes the evidence supporting each of the recommendations.

And lest you think we’ve just distilled gynecology into an app, remember that not every patient fits an algorithm. Not all patient populations are suited to follow-up, particularly those who may have spotty or intermittent care. Fortunately, most of the algorithms provide options for management that will allow almost any woman and her provider to come to a management decision that’s right for her.

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• ASCCP Guidelines for Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors (PDF) (May 2013) (Note – fig 15 in the pdf has an error, so use the Algorithm link below for the corrected version)
• ASCCP Consensus Guideline Algorithms (May 2013)
• USPSTF Guidelines on Pap screening (March 2012)

Most tourists don’t make it above 72nd St, and so they never see one of Central Park’s most special spots – The Conservancy Garden.

My favorite times to visit the garden are right about now, when the trees and tulips are in bloom and in early summer when the wisteria blossom.

But anytime is the right time to enjoy this oasis of quiet beauty and sweet dignity in the city.  (Also a  bathroom with no lines…)

It’s even more special if you visit the garden with two very dear friends, as a little detour on your bike ride around the Central Park Loop.

Add in a pre-ride coffee with the girls at the Columbus Circle park kiosk and a  stop to watch the guys play ball at the Heckscher Fields in the south park,

then convince MR TBTAM (who skipped the ball game that day so he could run errands – what was he thinking?…) to bike over and join you all for a post-game/post-ride lunch at the Ballfields Cafe, and I would say that you have had one very perfect Sunday outing.

A  breast cancer survivor takes a long hard look at the myths and realities of mammography.

I used to believe that a mammogram saved my life.

Bottom line – Mammography is not perfect, and like all screening tests, has risks as well as benefits.  Mammograms lower breast cancer morality by 15%, but at a cost of over-diagnosis, and some believe, over treatment of cancers detected by screening that may never had caused death in the first place.  This is most evident in the increasing use of mastectomy to treat DCIS, a non-invasive form of breast cancer that is readily detected by mammography.

A must read for every woman considering having a mammogram.

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More on mammograms -

• The New Mammogram Guidelines - What you need to know.
• Mammograms – what women want. But is it for the right reasons?
• ACOG’s Mammogram recommendations - not what you’d think
• Preventing Breast Cancer Deaths - How much credit does mammography get?
• Understanding Mammogram Over-Diagnosis
• More on Mammogram Over Diagnosis
• Breast Cancer Mammogram Density Laws

For now, here’s a little bit of inspiration from one of my fave movies of all time, Camp. It’s for those of us of a certain age wondering if their time has passed. (It hasn’t.) Watch the whole thing -the best part is at the end.

Outside my house is a cactus plant they call the century tree.
Only once in a hundred years, it flowers gracefully.
And you never know when it will bloom.

Hey! Do you wanna come out, and play the game?
It’s never too late.

While I’m at it, here’s another blast of energy from Camp. (Did I say how much I adore this movie?)