One of the most potent acupuncture points of all lies on the Stomach meridian. Its Chinese name, Zusanli is translated as Leg Three Miles. It was a point reputedly known to be used by ancient Chinese soldiers to enable them to walk an extra three miles after exhaustion. This point strengthens the legs and tonifies Qi and blood to help eliminate fatigue.

ST 36 also treats most digestive issues such as nausea, vomiting, reflux, belching, stomach cramps, bloating, flatulence, diarrhea, low appetite and poor digestion. Even more importantly, it improves the immune system, treating chills, fever, asthma and even alleviates depression.

This is such a magical point, it is known to treat all diseases and the ancients said that by the daily stimulation of this point, you can live to be 100! Modern studies on the use of acupuncture or moxabustion on ST 36 produces measurable changes in the areas of the brain related to gastric function.

This powerful point is found on the lower leg, three finger widths (or three inches) below the base of the patella (knee cap), one finger’s width lateral to the ridge of the tibia and in the shin muscle. You know when you have found it when you fall into a slight depression the size of a quarter, which you may find to be sensitive. It’s a bit like putting on the golf course. Massage or rub vigorously to stimulate your immune system. I’ve been using it on all my clients lately.

One of my clients who was a professional baseball player always wanted to come for treatment before a big game to stimulate “leg three miles point”. It helped him avoid shin splints and recover more quickly after games. His experience was a modern equivalent of those ancient soldiers who were able to march further by supporting the Stomach channel.

Useful information for Women about Breast Problems and Breast Disease.

BREAST PAIN

The first step in evaluating "breast pain" is to determine whether the pain arises from the breast or from the underlying chest wall. This distinction can be made by physical examination. A surprisingly high percentage of "breast pain" is actually due to the chest wall arthritis, muscle overuse, or muscle strain.

The cause of most breast pain is poorly understood, but appears to be due to an increased sensitivity of the breast tissue to normal levels of hormones. In most instances, it appears without warning, may last for several months, and then spontaneously disappears. In some cases, it can be so severe as to be debilitating.

Breast pain almost always disappears at menopause. Only about 10% of breast cancers present as painful masses.

Powerful hormones are available that usually will relieve the breast pain. They are usually prescribed for a year. After that they are stopped, the pain returns in half of the patients. The powerful hormone treatment has some side effects. Particularly, hormones are harmful to the fetus if you should become pregnant so some form of mechanical contraception is required before they are prescribed.

Caffeine abstinence is not as effective as are hormone treatments and works in considerably fewer women. It is difficult to determine just how effective or ineffective caffeine abstinence is because of the variable nature of breast pain.  However, given the problems sometimes encountered with the hormonal treatment,caffeine abstinence should be give a conscientious trial for several months as the initial treatment for breast pain.

BREAST LUMP

The normal breast consists of a mixture of soft fatty tissue and firmer glandular tissue. Normal breast glandular tissue in premenopausal women can be irregular so it is sometimes difficult to determine if an area is really a lump or if it is nothing more than breast tissue. Unfortunately, mammograms cannot be trusted because they missat least 20% of breast cancers. Therefore, judgement is used to determine whether an area in the breast is sufficiently different from normal to warrant further investigation.

If an area is not felt to be abnormal, you still should do breast self-examination and return for re-evaluation if there is a change in the size or character of the questionable area. A woman cannot be told with certainty that she does not have breast cancer unless all breast tissue is totally removed and examined; a course which is usually considered impractical.

Breast lumps may be either solid or cystic. If a questionable area is found on physical examination, it can be immediately diagnosed by aspirating the lump with a fineneedle. The needle is passed into the lump and almost always fluid or cells can be withdrawn. If non-bloody fluid is obtained, the lump disappears, and there is no lump 6 weeks later when the breast is re-examined, the lump is considered to be a benign cyst. In 96% of lumps from which fluid cannot be withdrawn, cells are obtained with the fine needle and these are examined under a microscope. As with any diagnostic test, diagnosing breast lumps from aspirated cells is not 100% accurate. The ability todiagnose accurately depends upon who obtains and who diagnoses the sample. In my hands, diagnostic breast cancer cells are obtained from 97% of cancerous lumps.

Additionally, a biopsy is needed to exclude cancer in 5% of benign cases when the cytology is questionable. These results are as good as anywhere in the world but are still not 100%. Therefore, fine needle aspiration biopsies are done with the understanding that it is not perfect and that you will either have the lump removed or will return for re-examination at 3 and 12 months if you do not have the lump removed.

BIOPSY FOR THE "ABNORMAL" MAMMOGRAM

The first thing to recognize is that mammography is not a perfect test. It raises questions of the presence of breast cancer in 10% of normal women and misses at least 20% of breast cancers. The second problem is that no physician can ever tell you that you do not have breast cancer. Mammographic "abnormalities" can be definitively evaluated only by a biopsy. A biopsy may be done in either of three ways.

One, surgical excision of the area after the area in question is localized by mammography and a needle or wire is placed to guide the surgeon. Two, stereotaxic core needle biopsy where the questionable area is localized by mammograms andseveral cores of tissue are removed with a large- bore needle. Three, ultrasonic localization and fine needle aspiration of those abnormalities that can be identified by ultrasound.

The determination of whether a biopsy is needed or not in your specific instance depends upon the mammographic pattern of the questionable area and the way you tolerate not knowing for sure that an area is not cancerous. Some mammographic patterns are associated with a 75% incidence of breast cancer where as others areassociated with a 3% incidence. You must make the decision whether or not to have a biopsy. To help you decide this, you need to know how frequently the particular abnormality in your mammogram is caused by breast cancer. Depending upon the statistical risk of breast cancer, you have the choice of electing either a biopsy or a repeat mammogram to see if any change has occurred in 5 or 6 months. Whether a 5 or 6 month delay is harmful if the abnormality is breast cancer is unknown but is generally thought not to make a difference. Ultimately, the decision of whether or not you elect a biopsy is determined by how dangerous you perceive this abnormality to be.

LYMPH NODE DISSECTION

WHAT IS A LYMPH NODE DISSECTION?

• This is a surgical procedure which isusually done at the time of lumpectomy or mastectomy. With a lumpectomy, it is performed as a separate incision (cut) under the armpit; with a mastectomy it is an extension of the breast incision toward the armpit. The surgeon removes part or all of the lymph nodes in the armpit. During this procedure a nerve is usually cut which normally carries sensation to the armpit and part of the skin below it. Cut nerves usually do grow back but very slowly and often incompletely.

WHAT IS LYMPH NODE SAMPLING?

• Some of the lymph nodes under the arm (axillary) drain the breast, but others drain the arm and back. When all the axillary nodes are removed, the drainage to the arm is disturbed. In order the preserve as much arm drainage as possible, only some of the node may be removed...sampled.  This can be done with guidence from radioactive materials, dyes, or anatomically.  Sampling may miss cancer-containing lymph nodes, but this probably does not affect survival. However, additional surgery may be necessary if the nodes become enlarged and can be felt on physical examination.

WHY IS LYMPH NODE REMOVAL DONE?

• It is done to determine if the cancer has the propensity to spread beyond the breast. If cancer has spread to the lymph nodes, the likelihood of its having spread elsewhere is greater than if it has not spread to the lymph nodes.

WHAT IS THE FUNCTION OF LYMPH NODES?

• They act as "filters" to collect foreign material like bacteria and prevent them from reaching the blood stream. After the lymph fluid leaves the lymph nodes it travels to the blood stream. Lymph nodes are an important part of the body's defense against infection. Breast cancer cells which break off from the tumor frequently travel through the lymph fluid to the lymph nodes where they get trapped.

HOW DOES LYMPH NODE DISSECTION HELP?

• It helps your doctors determine the odds that your cancer has spread. This in turn will help them decide what additional treatment is needed based on estimates of your chances of living five years or more.

WHAT ARE THE LIMITATIONS OF THE INFORMATION OBTAINED?

1. Having a lymph node dissection does not change your chances of being cured. Your long term survival is determined by whether cancer has already reached your blood stream.
2. Prognostic information obtained from lymph node removal is inaccurate. In actual numbers, as many cancers recur in patients whose lymph nodes are negative as in patients who have positive nodes. However, the percentages for recurrence are higher for patients having cancer in the lymph nodes.

SHOULD EVERYONE HAVE A LYMPH NODE DISSECTION?

• No, there are a few cancers that have been noted to have such a low lymph node occurrence that lymph node dissection may not be advised by your doctor. These include carcinoma in-situ where the tumor is less than 2 1/2 to 3 cms, and cancers that are 0.5 centimeters or smaller. Some other breast cancers have cell characteristics that are less aggressive and less likely to spread. Women who have these types of cancer should carefully weigh the risks and benefits of node removal. If a woman chooses not to have a node dissection, nodes would be removed at a later time if they enlarged to the degree that they could be felt.

WHAT ARE THE ADVANTAGES OF LYMPH NODE SAMPLING?

1. Women who have had node sampling rarely have significant problems with long term are swelling. About 15% of women with total node removal have problems with arm swelling; this is severe in 1-2%.
2. Persistent upper arm pain is more common in total node removal (16%), particularly in women over 60 and those having a mastectomy.
3. Because some of the lymph nodes remain after sampling, the arm is better at fighting infection.  Node sampling ideally requires immediate analysis of the removed nodes, called frozen sections, which may not be possible at all hospitals. In sampling, frozen sections enable the surgeon to determine the need for more extensive node removal at the time of the surgery, potentially avoiding a second operation. Frozen section analysis extends the duration of the surgery. Additionally, frozen sections may not find cancerous foci in nodes that later are found to contain cancer when they are more thoroughly examined by permanent section.

WHAT DOES IT FEEL LIKE AFTER LYMPH NODE REMOVAL?

1. After surgery the armpit and the skin under it along the chest are usually numb (without feeling when you touch them). This numbness will last a long time, many months to years. Some sensation will come back in about 75% of women, but it may be incomplete.
2. In about 60% of women, the numbness is accompanied by prickling, tingling, burning, or the sensation of an open sore along the arm. 3) You will probably experience sharp, shooting pains that decrease over time. 4) Your shoulder and armpit may ache and/or it may feel like you have a large lump in your armpit. 5) You will only be able to raise your arm part way at first. 6) Your arm may feel weak. 7) You will feel a constricting feeling around your chest which will slowly decrease over months to years.

HOW LONG DOES IT USUALLY TAKE TO GET BACK NORMAL USE OF MY ARM?

• After surgery someone needs to instruct you on exercises for your arm. This may be your doctor's nurse or you may be referred to a physical therapist. You can also get advice from Back to Recovery. With a vigorous program of daily exercise most women are able to do their normal daily activities (called functional range of motion) by 2-3 months. Total range of motion (ability to move this arm as well as your other arm in all directions) is generally attained by 5-7 months. Women with lumpectomies tend to have the shorter times and those with mastectomies the longer.  However, when radiation is given following a lumpectomy, long- term arm mobility is better after a mastectomy. Muscles become weak fairly quickly when they are not used and strengthened gradually with increased use. Muscle weakness does not always occur; if it does, normal strength usually returns by a year.

WHAT CAN I DO TO PREVENT INFECTION IN MY ARM?

• Avoid even trivial injuries to the hand and arm, e.g., wear gloves when gardening.

WHAT CAN I DO IF I GET ARM SWELLING?

1. Keep your arm elevated as much of the time as possible.
2. Wear an elastic sleeve. These can be ready made or custom fitted. They may include only the arm (wrist to armpit), or extend to the palm (called a gauntlet). Elastic gloves are also available.
3. If numbers 1 and 2 are not sufficient, your doctor may recommend the addition of a compression pump which ia a pneumatic sleeve that squeezes out the edema each day. Elastic sleeves and pneumatic sleeves are available at stores that sell breast prothesis.

WHAT CAN I DO IF I HAVE PAIN ALONG MY ARM AFTER LYMPH NODE REMOVAL?

• Some women have tingling, prickling or the sensation of an open sore or burn along the arm. An over-the-counter cream called Capsaicin can be applied 3-4 times a day for two to three months, or longer if needed. It costs about $10-25 (1994 price) for a 1.5 ounce tube for normal strength (0.025%), or about $30 (1994 price) for Capsaicin high potency (0.075%).  Electing "Maximum" versus "Minimum" Treatments for Invasive Breast Cancer. 

Breast cancer is an unpredictable disease with a vast array of treatment options. The question is whether the patient and her doctor elect to pursue a course that utilizes all possible treatment possibilities (maximum) or elect to utilize only those of proven substantial benefit (minimum). This paper deals with the emotional factors that tend to influence treatment selection.

The ultimate problem with breast cancer is that it may reappear at a later date in a remote site. This is called distant metastases and the cancer cannot be cured at this stage. After a cancer has been discovered in the breast, both the patient and her doctor want to do everything possible to prevent metastases from happening. Unfortunately, with invasive cancer, distant metastases have occurred by the time that the original cancer is diagnosed in the breast. Whether this happens or not is determined by as yet unknown features inherent to the breast cancer. All breast cancers are different but behaviorally they can be classified as good or bad. The good cancers lack the inherent ability to spread to distant sites and are cured by removing the cancer in the breast. The bad cancers have spread to distant sites before they are detected. This spread usually consists of single or small cell clusters that lie as undetectable microscopic deposits. These cells grow at varible rates, but, on the average, they become detectable within two years. However, many years pass in other instances before these cells become apparent.  There is a compelling urge for women to actively fight their breast cancer. Their urge is met by finding a balance between doing that which is proven to affect the disease and that which possibly may affect the disease. Everyone wants to do everything rational to fight the cancer, but the definition of "rational" is the issue. What is rational for one may be irrational for another. Ideally, women should be given ALL the facts concerning treatment efficacy and the complications so they can weigh the risks and benefits. Most breast cancer patients have a VERY inflated idea of the benefits of therapy and are willing to take unreasonable risks to attain a false sense of security. Unfortunately, most women do not have the medical background to weigh all the potential benefits versus all of the potential risks for the myriad of treatment options available for breast cancer. They need someone to put every possible factor into the mix, come up with the best guess of risks and benefits, and then tailor a recommendation to fit the individual.

Patients think toxic medicine is better medicine and maximum treatment will result in a greater likelihood that they will be cured. In a way this isn't bad because if things go badly they feel that they have done everything possible. The same is true from the doctors perspective. If every possible treatment has been given for the original breast cancer, later, in retrospect, the patient cannot blame the doctor if the cancer returns. In addition to the possible loss of credibility in the patient's eyes, doctors fear being sued. There always are "hired gun" experts that lawyers can retain who will testify that the cancer would not have come back had an additional therapy been given.

The argument for selecting minimal treatment can be summarized by stating that few if any breast cancer treatments convincingly increase the chance of being cured. Removal of the original cancer from the breast prevents it from becoming bulky and ulcerated. Removal of lymph nodes from under the arm is done in an attempt to estimate the probability that the cancer will recur. Such estimates are very inexact.

Administration of chemo- or hormonal therapy is done in hopes of eradicating the already present distant metastatic deposits although the data supporting this are rather weak.

Since all therapies have side effects, the reason for selecting any treatment deserves careful consideration and close scrutiny.

• Usually, the cancerous breast is removed or the breast is irradiated after cancer excision in order to reduce the likelihood that either it or another cancer will reappear in the breast.

• With some relatively small cancers simple excision is all that is needed.
• Breast irradiation produces long-term side effects.
• Reconstruction, either immediate or delayed, can be considered.

• Usually, axillary lymph nodes are removed.

• Their removal for treatment is unnecessary unless they are felt to be enlarged.
• The prognostic estimates that are based on cancerous involvement of these nodes are very inexact.
• Cancerous nodes may be missed, but outcome unaffected, if they are sampled rather than completely removed.
• After the nodes are removed, the arm becomes susceptible to infection and some swelling occurs in 15% of patients.

• Frequently, chemo- or hormonal therapy is given after surgery.

• On an average, such therapy delays any recurrence that is destined to occur.
• Administering such therapy may be delayed and given only when and if recurrence appears. There is no convincing evidence that the chance
• of cure is increased or survival is prolonged by giving such therapy immediately after surgery.
• If a cancer is inherently good and has been surgically cured, then chemotherapy is unnecessary and without benefit.
• Each type of chemo- and hormonal therapy has its own set of short and long term toxicities.

The patient must live with decisions that are made shortly after the breast cancer is diagnosed. Usually, personal factors are as important as "cancer" factors in arriving at treatment decisions. From a variety of options, the patient must select those treatments that best fit her personality and life style. What is "best" for one patient may not be "best" for another.

Hormonal Replacement therapy, Cardiovascular disease, and Osteoporosis Prevention

Estrogen is commonly given to postmenopausal women for osteoporosis prevention and to reduce the risk of heart disease. Unfortunately, this type of estrogen replacement also causes breast cancer. Estrogen given after menopause continues to stimulate the breast causing fibrocystic lumps and it also increases the risk of breast cancer. The best study (the Nurses Health Study) reported the risk of breast cancer for current takers who took hormones for five or more years was 46% higher and the risk of breast cancer deaths was 45% higher than in non-takers. The risk returned to normal two years after stopping.

Cardiovascular disease

Cardiovascular risk factors are defined as current smoking, high cholesterol levels, high blood pressure, diabetes, a parental history of premature myocardial infarction, or body-mass index of 29 or higher (obese). In such postmenopausal individuals, the Nurse Health Study showed a 49% decrease in deaths from all causes for current hormone users as compared with these who had never used hormones. The decrease in deaths was not significant (13%) in women without such risk factors. Moreover, after 10 or more years of hormonal replacement therapy the decrease in cardiovascular deaths was offset by the increase in breast cancer deaths.

In another study, estrogen replacement therapy did not decrease second heart attacks in women who already had one heart attack.  Although making lifestyle changes is not easy, many cardiovascular risk factors can be eliminated by healthy living habits. Additionally, cholesterol lowering medications are more effective than estrogen in lowering cholesterol. Other risk factors such as high blood pressure can be medically controlled.

Osteoporosis

Approximately 50% of postmenopausal women need some sort of therapy to maintain their bones above the fracture threshold until the age of 70. Moreover, nearly all women need therapy if they wish to keep their bones above the fracture threshold for an entire life to age 80 or 90. Understanding normal bone changes during normal life is important in order to determine who needs preventive treatment and when it should start.

Peak bone mineral density occurs by age 16 and progressively decreases thereafter. The rate of loss accelerates at menopause but 70% of the total loss to be experienced will have occurred by that time. Bone mineral density (BMD) measures bone strength.

Women who have low bone mineral density in their teens will continue to be low. Increased susceptibility to osteoporotic fractures can be identified by bone mineral density determinations that are at least 2 standard deviations below the mean value found in premenopausal white women. Approximately 5% of normal women aged 40- 49 years, 20% of women aged 50-59 years, and 45% of women aged 60-69 years have a BMD below this threshold. Therefore, comparing your BMD with that of normal young women will give a good idea of your susceptibility to osteoporosis.

The most physiological way to slow down the loss of bone mineral is with exercise and dietary calcium supplimentation. However, taking postmenopausal estrogen replacement is easier, avoids hot flashes, and is more potent and more effectively retards the loss of bone minerals. Moreover, hormones only slow the rate of loss of BMD rather than increasing BMD.

A lot of research has been going on to develop drugs that provide the beneficial effects of estrogen while avoiding the detrimental ones. In 1995 the first of a series of new drugs, bisphosphonates, was approved for treating postmenopausal osteoporosis.

The first of these drugs was alendronate, and in 1997 risedronate was approved. Risedronate is less irritating to the stomach than is alendronate. In 1997 the first of another type of hormone-like drug, raloxifene, was approved for osteoporosis prevention. Drugs such as raloxifene may prove to have beneficial estrogen-like effects in preventing cardiovascular disease. In contrast to estrogen, these drugs have no untoward breast effects and actually increase bone mineral density.

Since postmenopausal osteoporosis prevention entails medication for the rest of one's life (one pill a day), it is reasonable to treat only when there is evidence of a potential problem. Increased risk factors include:

• family or personal history of osteoporosis or fractures,
• thin, small build,
• lifestyle factors: inactivity, excessive alcohol or caffeine consumption, and
• smoking.

A woman has no control over two of these risk factors, namely family history and being born with a certain body type. However she has control over her lifestyle risks.  Beginning an exercise routine, smoking cessation, and minimal to moderate alcohol and caffeine consumption are keys to reducing one's chances of developing osteoporosis. A bone mineral density test is valuable to determine the overall risk of osteoporosis. More importantly such a test can be used to determine when a woman should start pharmacologic therapy.

In summary, every woman needs to be informed about the benefits and risks that accompany estrogen replacement along with alternative methods of reducing heart disease and osteoporosis. There are other means of preventing and treating heart disease and osteoporosis, but there is no way to prevent breast cancer.

Surgical Breast Cancer Treatment Options

Most women with a diagnosed breast cancer have two major concerns: 1) will the cancer recur and kill them and 2) do they have to lose their breast (i.e. have a mastectomy). An additional concern is the way in which treatment will affect their body's physical function. Both the physical and emotional effects of breast cancer can be long-lived so it is best to be well informed before you enter into a specific treatment course. You will accept both your physical and emotional disruption better if you are involved in making treatment decisions. However, some women prefer that their doctor make decisions for them. If you prefer it that way make sure that the doctor understands what is important to you and that you understand that any decision may turn out to be wrong in retrospect.

Let's talk about what effect surgical treatment has on whether or not the cancer will recur. The first and most important thing to remember is that not all breast cancers are the same. Bad cancers cancers spread to remote sites in the body by the time the cancer is diagnosed; good cancers can grow in the breast and get to be quite large before spread occurs. Unfortunately, there is no reliable way to tell whether the cancer has spread . Blood tests, Xrays and scans usually cannot detect the small cells that may have broken off from the original cancer and have lodged in remote body locations. Only time will tell whether spread has occurred. How the breast is treated (lumpectomy or mastectomy) has little if any effect on its ultimate cure..

Again, cancer spread is determined by whether the cancer is inherently good or whether it is inherently bad. The microscopic appearance of some cancers makes it unlikely that spread will occur, but the best way to predict the future course of most cancers is by removing lymph nodes from under the arm, called an axillary lymph node dissection, and examining them under a microscope for cancer. Information obtained from examining these nodes is important in determining the type and intensity of chemotherapy that is recommended. Cancers that have spread to these nodes are more likely to have spread to other sites in the body than those that have not. The reasons for examining lymph nodes are the same regardless of whether the cancer in the breast is treated by lumpectomy or mastectomy. Hopefully, in the future, computer analysis of cells from the original breast cancer will give more accurate predictive information than is obtained from examining lymph nodes and therefore will make their routine removal unnecessary.

Now, we'll talk about how to treat the cancer in the breast. The two options are lumpectomy or mastectomy and another option is reconstruction after a mastectomy. The only reason to elect a lumpectomy is to preserve body image. Tumor size and location may make lumpectomy unadvisable. Radiotherapy is usually given to the breast after lumpectomy, but even then cancer recurs in the breast at the rate of 1 to 2% per year. However, cancer recurrence in the breast usually is less serious than is cancer recurrence elsewhere and can usually be treated successfully by a mastectomy.

If you elect to have the original breast cancer treated by a mastectomy, the breast is gone and radiotherapy usually is unnecessary. There are pros and cons to bothlumpectomy and mastectomy that you should be aware of before you select one or the other. In either event, we have found that women adjust equally well to their choice.

C-reactive protein (CRP)

The condition is low-grade inflammation, which may originate in a variety of unlikely places throughout the body, including even excess fat. New federal recommendations are being written that will urge doctors to test millions of middle-aged Americans for it.

The discovery of its surprising ill effects is causing a top-to-bottom rethinking of the origins and prevention of heart trouble. Doctors call it a revolutionary departure from viewing the world's top killer as largely a plumbing problem blamed on cholesterol-clogged arteries, the standard theory through the modern era of cardiology.

"The implications of this are enormous," says Dr. Paul Ridker of Boston's Brigham and Women's Hospital. "It means we have an entire other way of treating, targeting and preventing heart disease that was essentially missed because of our focus solely on cholesterol."

Testing Healthy People

In the past year or two, experts say, the evidence has become overwhelming that inflammation hidden deep in the body is a common trigger of heart attacks, even when clogging in the arteries is minimal. Now the main question is: How aggressively should otherwise healthy people be tested to find and treat it?

The new recommendations are still being drawn up, but they will offer the first formal blueprint to answer this, probably sometime in the fall. Doctors writing them say they will almost certainly recommend broad testing.

Inflammation can be measured with a generic $10 test that looks for high levels of a chemical called C-reactive protein, one of many that increase during inflammation. Experts expect it to quickly become a standard part of physical exams. As a result, many people ordinarily consid- ered at low risk will probably be put on statin drugs, which lower inflammation as well as cholesterol.

No one disputes the importance of cholesterol. Yet half of all heart attack victims have levels that are normal or even low. Clearly, something big was missing from the equation, and that appears to be inflammation.

Ridker estimates that between 25 million and 35 million healthy middle-aged Americans have normal cholesterol but above-average inflammation, putting them at unusual risk of heart attacks and strokes.

A series of landmark studies by his team, beginning in 1997, suggest inflammation is more important than cholesterol at triggering heart attacks. They found those with high levels of C-reactive protein have twice the risk of people with elevated cholesterol.

High amounts of the protein also predict increased risk of heart attacks and strokes years before they occur, even when cholesterol levels are low. Having both inflammation and high cholesterol together is especially ominous, resulting in a nine-fold increase in risk.

Everyone who reaches middle age has some degree of fatty buildup, called plaque, in the heart arteries. The new evidence suggests it becomes threatening if weakened by inflammation, which makes it squishy and fragile. Even a small lump of plaque can burst like an overripe pimple, prompting the formation of a clot that in turn chokes off blood flow and causes a heart attack.

Many people with no outward signs of anything wrong have high levels of internal inflammation. It is exactly the same sort that causes swelling, heat and redness during infections or allergic rashes.

Doctors believe the internal inflammation has many possible sources. Often, the plaque itself becomes inflamed as white blood cells invade in a misguided defense attempt. But inflammation that arises elsewhere apparently can be as bad, for it bombards the plaque with damaging chemicals.

For instance, fat cells churn out these inflammatory proteins, which helps explain why being overweight is so bad for the heart. Other possible triggers include high blood pressure, smoking and lingering low-level infections, such as chronic gum disease.

Although many chemicals increase during inflammation, C-reactive protein, or CRP, is particularly easy to measure. Some already test for it, including White House doctors, who checked President Bush's CRP level last summer. (His was extremely low.)

CRP Recommendations

In March, the Centers for Disease Control and Prevention and the American Heart Association held a meeting of 50 experts in Atlanta to review the scientific evidence on inflammation and make recommendations.

These are still being discussed, but some doctors involved say they are likely to urge CRP screening for people already considered at mild to moderate risk of heart attacks. These include smokers and those with a combination of other less ominous risks, such as being middle-aged and having borderline high cholesterol or blood pressure. For instance, they might recommend

CRP testing for a 45-year-old man with cholesterol in the low 200s and blood pressure just be- low the cutoff for treatment.  However, others believe CRP should measured in everyone over age 40, just like cholesterol, regardless of their other risk factors.  "It begins to look like a standard risk factor that one would evaluate at least once in middle age in most people," says Dr. Wayne Alexander of Emory University, one member of the recom- mendations committee. "This is a very important concept for the general public to be aware of and to think about for their own health."

Doctors hope to have the recommendations ready for publication in the journal Circulation in November, followed by a campaign to teach doctors and ordinary people about it. "Our goal is to have a broad-based consensus and use all available means to disseminate that information widely," says Dr. George Mensah, the CDC's chief of cardiovascular health.  Many hospitals can already do the test. However, until the recommendations come out, most doctors are unlikely to know exactly whom to test or what to make of the results. In fact, the White House doctors who checked Bush had to call Ridker to figure out how to interpret his numbers.

The Effects of CRP Screening

CRP probably will not matter much for heart attack survivors and others who already know they have heart disease, since presumably doctors are already doing everything they can to keep their condition from getting worse.

"We believe the niche for C-reactive protein - and it is a large niche - is the healthy population who want to do what they can to lower their risk of cardiovascular disease," says Dr. Richard Cannon of the National Heart, Lung and Blood Institute.

Screening is important because inflammation can be readily lowered in several ways. One of the most powerful is losing weight. Exercise also helps, as does moderate alcohol intake, giving up smoking and lowering blood pressure.

Of course, this amounts to the same healthy living advice that doctors have long dispensed. But now they have a much better understanding of why it works so well. Furthermore, they are likely to urge these habits on people with bad CRP readings who until now would have seemed to be at no special risk of heart problems.

Many of the standard heart medicines also lower inflammation. These include aspirin, Plavix, ACE inhibitors and the statin drugs, such as Lipitor and Zocor. The statins are now prescribed to lower cholesterol, and they do so dramatically. But studies have shown they ward off heart attacks much more powerfully than would be expected from their effects on cholesterol alone. In fact, people with moderate cholesterol seem to benefit just like those with readings off the charts. Lowering inflammation probably explains why.

Still, some important details remain to be settled. One is population-wide data on CRP levels and their connection to heart disease. Ridker is finishing a large study, to be released later this year, that traces this relationship with CRP readings from tens of thousands of people.

"Paul has got data now that slam-dunks it," says Dr. Richard Milani of the Ochsner Clinic in New Orleans.

Another gap is rock-solid evidence that lowering inflammation truly prevents heart attacks and saves lives. Ridker hopes to prove this with a study to begin this fall that will compare statin drugs and dummy pills in 15,000 middle-aged men and women with normal cholesterol and above average CRP.

The new thinking about inflammation "will change everything we do in heart disease," predicts Dr. Eric Topol, cardiology chief at the Cleveland Clinic.

"In the last decade, people talked about their cholesterol levels," he says. "In the next decade, the cocktail chatter will be, 'What's your C-reactive protein?' Everyone will need to know that."

WHAT IS FIBROMYALGIA?

Fibromyalgia (fibrositis, myofibrocytis) is a chronic, painful muscle condition characterized by pain in the skeletal muscles, tendons (which attatch muscles to bones), ligaments (which attach bones to bones) and other and bursa (sac-like structures which are filled with synovial fluid and provide lubrication and nutrition to joints). Recently, much has been written about this disorder in health magazines and newspapers. Although Hippocrates first described fibromyalgia, it has been only in the last few years that much attention (and credence) has been given to this syndrome. Contro- versy and disbelief by the medical profession has been associated with fibromyalgia simply because objective evidence in the form of x-rays or biopsies can't be found. However, with the use of thermography, or the measuring of heat produced by areas of the body, this syndrome is now more widely accepted by many, but not all, doctors.

SYMPTOMS

Fibromyalgia is characterized by generalized muscle soreness and stiffness lasting more than three months, poor sleep with morning fatigue and stiffness, tenderness at 11 of 18 specific sites, and normal blood test results. The more common painful areas are the low cervical spine, the shoulder, the second rib, the arm, the buttocks and the knee. These symptoms are often worsened by stress or a change in the weather. Depression, which may be due to a chemical imbalance in the brain or the development of chronic pain, is common with fibromyalgia. Virtually all physical activity not only increases the patient's pain complaints, but also makes the next few days miserable, producing intense muscle pain.

Note the location of specific tender points, 11 of 18 of which are required for the diagnosis of fibromyalgia to be made. From: Fibromyalgia & Chronic Myofascial Pain Syndrome: A Survival Manual, by Starlanyl, DJ and Copeland, ME. New Harbinger Publications: Oakland (CA), 1996.

CAUSES

Fibromyalgia may be caused by physical trauma (such as a motor vehicle accident, a sudden fall, or even the trauma of surgery with a general anesthetic). This terrible disorder may also begin after an illness like the flu. Often, women experience the effects of fibromyalgia due to hormonal changes after a hysterectomy or around the time of the beginning of menopause. Also, the sudden emotional trauma of the loss of a loved one may trigger fibromyalgia.

Many "experts" feel that fibromyalgia effects only those people with "Type A" personalities, but this notion has not been demonstrated either by statistics or by scientific experimentation. It may plague people with all types of personalities and life styles, all age ranges, and those in all states of health. However, many of those suffering with fibromyalgia also suffer with TMJ.

CONDITIONS ASSOCIATED WITH FIBROMYALGIA

Many other physcial conditions are found frequently along with fibromyalgia. Each of these can and do occur separately; however, they are also quite commonly associated with fibromyalgia.  TMJ. Many patients suffering with TMJ problems also sufferer with fibromyalgia. Unfortunately, many doctors (1) don't recognize either TMJ or fibromyalgia or (2) fail to see the connection of these two pain syndromes. Fibromyalgia almost always intensifies the painful symptoms of TMJ and when one or both temporomandibular joints are dislocated, the pain of fibromyalgia in the neck and upper back is greatly magnified. Both TMJ and fibromyalgia produce similar painful symptoms in the muscles of the neck, shoulders, back, face and head as well as often causing dizziness.

Chronic Fatigue Syndrome

• This debilitating disorder, just like fibromyalgia and TMJ, is often misdiagnosed and at best, misunderstood by many medical professionals. In addition to chronic fatigue, CFS, just like fibromyalgia, produces muscle pain and weakness.

Irritable Bowel Syndrome

• Nearly half of all patients with fibromyalgia have frequent bowel cramping, severe diarrhea, and severe abdominal pain.

Depression

• As with most conditions which produce chronic pain, depression is a common problem with fibromyalgia. Common depression symptoms include a feeling of low self esteem, helplessness, hopelessness, poor appetite, loss of sexual drive, sleeplessness, frequent crying, and basic lack ofinterest in life.

Anxiety Disorder and Panic Attacks

• Often, those afflicted with fibromyalgia also experience extreme anxiety and panic attacks, especially at nighttime. They may awaken in terror with their heart beating rapidly, their chest feeling tight with a feeling as if breating is impossible. The patient will be convinced that they are going to die. There are many causes of such attacks, and perhaps alterations in certain body chemicals produced in excess with fibromyalgia may be one cause.

Concentration and Memory Problems

• Like those suffering with severe TMJ, patient with fibromyalgia often report difficulty in thinking and even remembering. They often forget where they've parked the car at the mall, for example. Simple facts and numbers are often forgotten. Understandably, great frustration often accompanies these memory problems.

Irritable Bladder

• Those with fibromyalgia often complain of frequent, painful urination.  Although they feel as if their bladder is infected, urine and blood tests are negative.

Mitral Value Prolapse

• There may be a statistical correlation with those suffering with mitral
• value prolapse (a weakness in the mitral value of the heart) and fibromyalgia. Since the mi-
• tral value is mostly fibrous connective tissue, perhaps the same process that effects other
• connective tissue of the body (eg, musles, ligaments, tendons and bursae) also damages the
• mitral value of the heart.*

Fibrocytic Breast Disease and Endometriosis

• Although there is no known explaination (yet!), both fibrocystic disease of the breast and endometriosis are often seen in women with fibromyalgia.*. *Pellegrino, MJ. Fibromyalgia: Managing the Pain. Columbus: Anadem Publishing, 1993.

TREATMENT

• Treatment of fibromyalgia is physical therapy, trigger point anesthetic injections, stress management, non-steroidal anti-inflammatory drugs, dietary changes and antidepressant drugs, especially at bedtime. Recently, there has been a lot of research concerning the use of herbs and homeopathic remedies (eg, Vitamin C, Rhux Tox 6x, melatonin, magnesium, and many others) in the treatment of fibromyalgia. An excellent article addressing this and other issues about fibromyalgia appeared in the January 1996 newsletter of the USA Fibromyalgia Association (details are given below about the Association).
• Physical exercise, preceeded by stretching and followed by application of ice, is very beneficial. One of the worse things a sufferer of fibromyalgia can do is to become sedentary and inactive. You'll only gain weight, become depressed, and lose all desire to participate in life.

TMJ And FIBROMYALGIA

• Many sufferers of fibromyalgia also suffer with TMJ problems. In fact, each of these disorders make the other far worse than they'd be alone. When one or both TMJs are injured, the muscles in the head and neck automatically tense-up, develop trigger points, and, among other symptoms, intensify the symptoms of fibromyalgia. Unfortunately, many doctors who effectively treat fibromyalgia do not under- stand or recognize TMJ and visa versa. Also, many patients suffering with TMJ have been misdiagnosed as having fibromyalgia.

For more information about fibromyalgia, contact:

USA FIBROMYALGIA ASSOCIATION

P.O. Box 20408

Columbus, OH 43220

Phone: (614) 764-8010

X-Ray Vision in Hindsight: Science, Politics and the

Mammogram

By GINA KOLATA and MICHAEL MOSS

For decades, it was an article of medical faith: Get a mammogram; it could save your life.  Now, seemingly overnight, that faith has been shaken. The mammogram — that yearly ritual for millions of American women — has become the focus of a bitter and unusually public scientific dispute that is being fought in the pages of medical journals and the columns of daily newspapers. Scientists, policy makers and politicians have scheduled meetings and Congressional hearings.

In the end, though, there is not likely to be a quick answer to the central question of whether researchers were right when they said that screening healthy women reduces death from breast cancer or, to put it another way, whether women should still get that annual mammogram.

"What a mess, what a complete mess," said Cindy Pearson, executive director of the Women's National Health Network, an advocacy group that has been flooded in recent days with phone calls from anxious women. "They want to know what is all this based on, is there some sort of sneaky, behind-the-scenes thing going on?"

How that mess came to be is a story of science and politics and the business of medicine, and a war on cancer that seized upon mammography as a central weapon. It also is a story of the way science struggles toward an ever evolving "truth."

The mammogram has always been a modest weapon, with benefits that women must weigh against possible risks. It is a screening tool that misses some tumors. At most, studies have found, it can cut the breast- cancer death rate by 30 percent.

Even when mammograms do "work," what they find does not always turn out to be cancer. The cancer they find may be growing so slowly that it would never threaten a woman's life. The result can be surgery, radiation and chemotherapy that is not medically necessary.

Over the years, scientists and statisticians have quietly debated the merits of mammography. Most of the public debate, though, has focused on its effectiveness for women in their 40's. That was already in considerable doubt when the larger issue broke open last fall with the publication of a study by a pair of researchers based in Denmark. They argued that the clinical trials most often cited to support mammogram recommendations were too flawed to be reliable. Last month, an influential but independent panel of experts at the National Cancer Institute agreed and said it could no longer make a recommendation about whether women should be screened.

"These are huge issues," said Dr. Barnett Kramer, chairman of the panel and associate director of disease prevention at the National Institutes of Health. "They shake my confidence."

For its part, the cancer institute says that after reviewing the matter, it concluded that the new analysis did not refute evidence that mammography works, and that it is standing by its recommendation that women 40 and older be screened.

Many of those who did the original trials are vigorously defending their work. While there are flaws in the studies, they say, the Danish analysis exaggerated their significance and misinterpreted facts.

A number of experts agree.

"I think the trials have imperfections," said Dr. Steven Woolf, a member of the United States Preventive Services Task Force, a panel that reviews scientific evidence about disease prevention. "But the issue is whether they invalidate the studies. My own view is that they do not rise to that level."

Since a new trial would require tens of thousands of women and a decade for results, some scientists are talking about digging deeper and more carefully into the old ones.  Now, mammography supporters, led by the American Cancer Society, worry that the uncertainty will weaken the government's resolve. They say mammography is a leading reason that the breast-cancer death rate has been dropping for the last decade.

Others, including those skeptical of mammography, ask whether the decline is a result of better treatments, especially the drug tamoxifen. For them, the furor is an opportunity to turn the focus of the war against breast cancer toward better treatment and the search for a cure.

A leading skeptic is Dr. Donald Berry, a medical statistician at the M. D. Anderson Cancer Center in Houston, where techniques were developed in the 1950's that spread mammography throughout the nation. Dr. Berry is a member of the federal advisory panel that is backing away from its support of mammography.

"Breast people here think I'm doing a disservice to women, and I think they are doing a disservice to women," Dr. Berry says. "Who's right?"

A Eureka Moment

One evening in late 1970, Sam Shapiro took his research team to a Swiss restaurant in Manhattan, where he broke the news that transformed the medical and political approach to breast cancer.

Dr. Philip Strax, a radiologist who had begun impressing surgeons by finding tumors before they could feel a lump, was at the table. To see if the mammograms really worked, Mr. Shapiro, the research director at Health Insurance Plan of Greater New York, had begun a scientific inquiry called a randomized trial. He divided women, ages 40 to 64, into two groups, and gave mammograms to just one.

The study had paid off, Mr. Shapiro told his colleagues that evening. In the first seven years of the study, 81 of 31,000 women who had mammograms died of breast cancer, compared with 124 of 31,000 who were not screened, a difference in the breast cancer death rate of a little more than 30 percent.

"It was thrilling," recalls Dr. Raymond Fink, who was in charge of recruiting women for the study. It was, he adds, "one of those movie moments," like the scene in "The

Story of Louis Pasteur" when Paul Muni says, "I found the germ!"

Mammograms took off.

Before long, the National Cancer Institute, the American Cancer Society and other organizations issued guidelines telling women to have mammograms starting at age 40. The federal government advocated the breast X-ray like no other medical procedure. It pushed states to promote its use, compelled insurance companies to pay the bills and rode herd on the radiologists who did mammograms to ensure that they did a good job. Now, an estimated 30 million women are having annual mammograms, and many are having additional tests, like sonograms, when findings are suspicious. That leads to annual costs of more than $3 billion, said Dr. Martin L. Brown, an economist at the National Cancer Institute.

A Question of Age

From the start, there was concern among scientists that mammograms did not work as well for women in their 40's, whose denser breasts make tumors harder to spot and who are much less likely than older women to have breast cancer in the first place. To help resolve the question, some urged the cancer institute to halt its promotion of mammograms for these younger women until it did another scientific trial. Instead, in what became a string of flip-flops, the agency in 1977 merely stopped recommending mammograms for women in their 40's.

It reversed course in the late 1980's, citing new data that also helped persuade the American Cancer Society and other groups to promote screening for younger women.

Then in 1993, still more findings led the institute to abandon the screening recommendation for women in their 40's.

Each move was hotly debated, and the issue festered in scientific circles until 1997, when the agency's new director, Dr. Richard Klausner, asked the National Institutes of Health to convene a new panel.

Dr. Leslie R. Laufman, an Ohio cancer specialist, said that before joining the panel, she had never really questioned the evidence about mammograms. At 49, she said, she had been having the screening test herself. "I was walking the walk and talking the talk," she said.

But after spending four months reading more than 100 scientific papers and then hearing 32 presentations in a two-day meeting, she and others concluded that women in their 40's should not be told to get screened, and she made a personal decision not have the test herself.

The reason was twofold, the panel said. First, the evidence that mammograms helped was tenuous. Second, there were risks in getting screened.

Over the years, scientists have learned that not all breast cancer acts alike. Some tumors grow fast, others slowly. Furthermore, nearly one-fifth of the 230,000 or so cases of breast cancer being found every year are a condition called ductal carcinoma in situ, or D.C.I.S.

Mammograms are especially good at finding D.C.I.S. But the problem is that many if not most of these growths — the science on this question is weak — might never spread. Too little is known about breast cancer biology to tell which ones will pose a threat. Thus, women must run the risk of getting unnecessary and dangerous treatment: radiation, chemotherapy, surgery.

The panel presented its findings to an audience packed with radiologists and advocates, with boos and hisses punctuating the proceedings. Dr. Klausner created his own stir when he said that he disagreed with the panel.

Then Congress got into the act, instructing the cancer institute to recommend that women in their 40's have mammograms. The institute reversed course and complied.

"Now, women in their 40's will have clear guidance based on science and action to match it," President Bill Clinton had said.

But if the guidance for women in their 40's was murky, the consensus that screening worked for women in their 50's and 60's would soon be thrown into doubt.

The Doubters of Denmark

Dr. Peter C. Gotzsche said he had never thought much about mammography until the Danish Medical Association asked him to look into it.

As director of the Nordic Cochrane Center in Copenhagen, Dr. Gotzsche belonged to a research collective known as the Cochrane Collaboration, which is striving to improve the quality of scientific studies and reporting.

When he and his colleague Ole Olsen looked at the seven large clinical trials on mammography, they concluded that they were too flawed to support mammography recommendations, a finding they reported two years ago in the British science journal Lancet.

The report drew little public attention. It was their deeper analysis, published in October, that touched off a firestorm.

Dr. Gotzsche and Mr. Olsen cited a number of things they said weakened the research, including potentially inaccurate records of causes of death, differences in screening schedules and possible discrepancies in the health histories of women in one of the trials.

In that case, the HIP study in New York, 853 women in the mammography group were excluded because of a previous diagnosis of breast cancer; only 336 were dropped from the unscreened group. If the two groups really were equivalent to start with, and if an extra 500 or so in the unscreened group should have been dropped but were not, that would have been a serious problem, Dr. Gotzsche and Mr. Olsen said.

But while some leading medical experts were convinced, many study researchers maintain that the Danish critique misinterpreted data, failed to account for statistical adjustments that corrected problems, read too much into disparities in the numbers and raised alarming questions without offering evidence that the results were actually skewed.

For example, says Dr. Anthony Miller, who reviewed deaths in the HIP trial, the disparity in excluded women would have been a problem only if anyone with a prior history of breast cancer slipped into the final death tallies, thus distorting the results. Systems were put in place to avoid that, he says.

"They latched onto these small differences, which have ready explanations, and sort of magnified them," Dr. Miller said. Dr. Gotzsche says he stands by the analysis. "There are no objections that make us doubt what we have done," he said. The Danish critique also reported that the screened women had more medical and surgical treatments. Treatment is appropriate when it saves lives, but if the death rate from breast cancer was no lower in women who had mammograms, that raises questions, the researchers said, of whether the test does more harm than good.

Last month, the panel at the National Cancer Institute concurred with the Danish report and said it would be as rational for a woman to decide not to have the test as to decide to have it. The panel plans to rewrite the assessment that it posts on the cancer institute's Web site.

But others, including scientists who have looked skeptically at mammography over the years, say they are not convinced that the mammography trials were so flawed that their results should be ignored. "Over all, I am not persuaded," said Dr. Suzanne Fletcher of Harvard Medical School, who was chairwoman of a 1993 federal panel that reviewed mammography, "although I thought there were some very important and interesting issues that these authors have raised."

Still, Dr. Fletcher and others say they would like to see an independent committee have access to and review the original data from all the trials, including patient records, so that answers might be obtained to the questions the Danish research raised.

A Tool With Limitations

For women and their doctors, the uncertainty is immensely exasperating, given that nearly four decades have passed since researchers began trying to find out if mammograms work.

"The bottom line is that if you're still not sure whether it's good or not, it can't be that good," says Dr. Vincent Rajkumar, an oncologist at the Mayo Clinic. "It can't be phenomenally effective."

Moreover, scientists say that the value of mammography cannot be weighed without taking into account the complex biology of breast cancer and the increasing effectiveness of treatment.

Some tumors grow so fast that mammograms cannot spot them before they spread — and even if they could, the treatment might not be good enough to make any difference. In other cases, the treatment is so effective that it does not matter if the tumor is found with a mammogram or somewhat later, when a lump can be felt, voiding the whole need for early detection.

"An extreme example of that is testicular cancer," says Dr. Peter Greenwald, director of the division of cancer prevention at the National Cancer Institute, "where you can cure all stages, so you don't see a mortality benefit from early detection." For now, even as they acknowledge mammography's limitations, many doctors say it is the best tool they have. While mammograms might not catch some deadly tumors fast enough to make any difference, and they cannot predict which tumors will prove to be deadly, many doctors believe that early detection does help them save some lives.

"I can think of many women where a mammogram was helpful in picking up something before it had spread to the lymph nodes," said Dr. Lynn Hartmann, a breast cancer specialist at the Mayo Clinic. "So I am not at the point of saying we should discard this tool. Until we have a more effective substitute, I continue to recommend mammograms, and I continue to have them."

Still, if all the ambiguity is maddening, that is not to say that the debate is unwelcome.  When Dr. Gotzsche took the stage at a conference of the National Breast Cancer Coalition last May to present his work, he checked the path to the exit, fearing he might be run out of the hall. Instead, a third or more of the audience rose to applaud.

The group's president, Fran Visco, explained, "Many of our members have long felt that the data is poor, that we oversell screening to the public, that we don't talk about the risks and we don't focus enough attention on preventing breast cancer."

"They were thrilled to have someone question all that."

Medical DITI is a noninvasive diagnostic technique that allows the examiner to visualise and quantify changes in skin surface temperature. An infrared scanning device is used to convert infrared radiation emitted from the skin surface into electrical impulses that are visualised in colour on a monitor. This visual image graphically maps the body temperature and is referred to as a thermogram. The spectrum of colours indicate an increase or decrease in the amount of infrared radiation being emitted from the body surface.  Since there is a high degree of thermal symmetry in the normal body, subtle abnormal temperature asymetry's can be easily identified.

Medical DITI's major clinical value is in its high sensitivity to pathology in the vascular, muscular, neural and skeletal systems and as such can contribute to the pathogenesis and diagnosis made by the clinician.

Medical DITI has been used extensively in human medicine in the U.S.A., Europe and Asia for the past 20 years. Until now, cumbersome equipment has hampered its diagnostic and economic viability.  Current state of the art PC based Infrared technology designed specifically for clinical application has changed all this.

Clinical uses for DITI include;

1. To define the extent of a lesion of which a diagnosis has previously been made;

2. To localise an abnormal area not previously identified, so further diagnostic tests can be performed;

3. To detect early lesions before they are clinically evident;

4. To monitor the healing process before the patient is returned to work or training.

Skin blood flow is under the control of the sympathetic nervous system. In normal people there is a symmetrical dermal pattern which is consistent and reproducible for any individual. This is recorded in precise detail with a temperature sensitivity of 0.1°C by DITI.

The neuro-thermography application of DITI measures the somatic component of the sympathetic nervous system by assessing dermal blood flow. The sympathetic nervous system is stimulated at the same anatomical location as its sensory counterpart and produces a 'somato sympathetic response'. The somato sympathetic response appears on DITI as a localised area of altered temperature with specific features for each anatomical lesion.

The mean temperature differential in peripheral nerve injury is 1.5°C. In sympathetic dysfunction's (RSD / SMP / CRPS) temperature differentials ranging from 1° C to 10° C depending on severity are not uncommon. Rheumatological processes generally appear as 'hot' areas with increased temperature patterns. The pathology is generally an inflammatory process, i.e. synovitis of joints and tendon sheaths, epicondylitis, capsular and muscle injuries, etc.

Both hot and cold responses may coexist if the pain associated with an inflammatory focus excites an increase in sympathetic activity. Also, vascular conditions are readily demonstrated by DITI including Raynauds disease, Vasculitis, Limb Ischemia, DVT, etc.

Medical DITI is filling the gap in clinical diagnosis ...

X ray, C.T. Ultrasound and M.R.I. etc., are tests of anatomy. E.M.G. is a test of motor physiology. DITI is unique in its capability to show physiological change and metabolic processes. It has also proven to be a very useful complementary procedure to other diagnostic modalities.

Unlike most diagnostic modalities DITI is non invasive. It is a very sensitive and reliable means of graphically mapping and displaying skin surface temperature. With DITI you can diagnosis, evaluate, monitor and document a large number of injuries and conditions, including soft tissue injuries and sensory / autonomic nerve fibre dysfunction.

Medical DITI can offer considerable financial savings by avoiding the need for more expensive investigation for many patients.

Medical DITI can graphically display the very subjective feeling of pain by objectively displaying the changes in skin surface temperature that accompany pain states.

Medical DITI can show a combined effect of the autonomic nervous system and the vascular system, down to capillary dysfunctions. The effects of these changes show as asymmetry's in temperature distribution on the surface of the body.

Medical DITI is a monitor of thermal abnormalities present in a number of diseases and physical injuries. It is used as an aid for diagnosis and prognosis, as well as therapy follow up and rehabilitation monitoring, within clinical fields that include Rheumatology, neurology, physiotherapy, sports medicine, oncology, pediatrics, orthopedics and many others.

Results obtained with medical DITI systems are totally objective and show excellent correlation with other diagnostic tests.

Thermal Imaging in the Investigation of Deep Venous Thrombosis

Harding, J. Richard. St. Woolos Hosp., Newport (U.K.)

Preliminary assessment of clinically suspected deep venous thrombosis (DVT) of the lower limb by

thermography avoids the need for over one third of venograms or duplex Doppler ultrasound scans.

Clinical diagnosis of DVT is notoriously unreliable - hence the need for an accurate means of clini-

cal investigation. Untreated DVT is dangerous as it can progress to pulmonary embolism (PE)

which is frequently fatal or life-threatening. Treatment of DVT by anticoagulation poses risks of its

own however, and should not be undertaken without a confirmed diagnosis. Thermal imaging is

quick, simple, non- invasive, risk-free, cost-effective and highly sensitive in the initial investigation

of suspected DVT; a negative thermogram excludes DVT and avoids the necessity for further inves-

tigation. Thermal imaging is, however, non-specific; a positive thermogram has a number of possi-

ble causes and is an indication for further assessment by venography or Doppler ultrasound to con-

firm or exclude DVT. Thermography should be considered the initial investigation of choice in

clinically suspected DVT, proceeding to venography or Doppler ultrasound only when thermogra-

phy is positive.

INTRODUCTION

Deep venous thrombosis (DVT) poses an important diagnostic challenge in medical practice. Along with

secondary pulmonary embolism (PE), DVT is a significant cause of emergency hospital admission, and

also occurs in patients already undergoing hospital in-patient investigation or treatment; post-operative pa-

tients and those suffering from malignant disease (especially abdominal and pelvic malignancy) are par-

ticularly at risk. The major complication of DVT is of fragments of blood clot (thrombi) becoming de-

tached (emboli) and passing through the veins of the lower limb, the inferior vena cava, and the right

atrium and right ventricle of the heart into the pulmonary arterial circulation of the lungs where they be-

come lodged in, and occlude branches of the pulmonary arterial tree as pulmonary emboli causing pulmo-

nary infarction of the distal perfused pulmonary tissues. This is a serious and life-threatening event imme-

diately fatal in 30% of cases [1]. Fatal pulmonary embolism causes over 20,000 deaths annually in Great

Britain and accounts for 10% of all deaths in hospital [2].

DVT is treated by anticoagulation; this treatment has risks, in particular haemorrhage, and is expensive and

time-consuming and should not be undertaken without a confirmed diagnosis of DVT or PE. Clinical diag-

nosis of DVT is notoriously unreliable [2], hence the need for reliable investigations to confirm or exclude

DVT.

The traditional method of investigation of DVT, still regarded as the "gold standard", is lower limb veno-

graphy (phlebography)[3], which outlines the deep venous system of the lower limb with radiographic con-

trast medium giving excellent detail of anatomy and pathology. This suffers the disadvantages of being in-

vasive, at best uncomfortable for the patient if not painful, with risks of allergy to intra-venous injection of

contrast medium (at worst fatal), the potential of dislodging emboli from lower limb venous thrombi due to

the forced volume injection of contrast, irritation of the venous endothelium by the contrast medium actu-

ally causing DVT when not already present, precipitation of cardiac failure in susceptible subjects due to

the fluid load of hypertonic contrast medium drawing fluid into the vascular space, and exposes the patient

to ionising radiation with its attendant risks. Venography is also expensive for consumable materials

(mostly radiographic contrast medium and film).

Various other methods of investigation of DVT have been utilised including isotope scanning for lower

limb thrombosis, light reflection rheography, impedance plethysmography and measurement of C reactive

protein or fibrin degradation products, but none have gained widespread acceptance due to various draw-

backs.

In recent years, duplex Doppler ultrasound has gained popularity [4], replacing venography in many insti-

tutions, but it has the disadvantages of being time-consuming, operator dependent, interpretation being to

some extent subjective, and exclusion of DVT confined to the calf veins can be difficult or impossible [5].

Thermography was first described in the investigation of DVT in 1972 [6]. It has been shown that thermo-

graphic investigation of DVT can avoid the need for further investigation by venography or duplex Doppler

ultrasound [7]. Whilst thermography is non-specific, it has the advantage of being highly sensitive

(approaching 100%) [8], and is non-invasive, risk-free, does not expose the patient to ionising radiation, is

not operator dependent or subjective in interpretation, and it is simple, quick and cheap to perform.

In acute DVT, the presence of propagating thrombus in the deep veins causes increased skin temperature in

the affected lower limb due to the action of vaso-active amines on the capillary skin circulation [9]; thermal

imaging detects this increased skin temperature along with loss of the normal 3oc temperature gradient

down the affected lower limb [10].

The aim of this study was to prospectively assess clinically suspected DVT in order to determine what pro-

portion of patients could avoid further investigation by virtue of normal thermography.

METHODS

1,000 patients with clinically suspected DVT were investigated by thermography by a single operator over

a period of 6 years 3 months. Thermal imaging of the lower limbs was initially performed by liquid crystal

thermography using the NovaTherm apparatus, followed by imaging with an Aga Thermovision 782 infra-

red camera. The lower limbs are first equilibrated with normal room temperature for 10 minutes by posi-

tioning the patient supine with both legs fully exposed and slightly elevated, with the heels supported, al-

lowing free circulation of air over the skin, away from localised sources of heat or cold such as radiators,

direct sunlight or draughts. Images are then obtained of the anterior aspect of both thighs, the antero-medial

aspects of the calves, and the posterior calves.

RESULTS

There were 362 male (36.2% of total) and 638 female patients (63.8% of total). The males had an age range

of 22-91 years and the females an age range of 15-96 years with a mean age of 65.0 years for males and

63.5 years for females.

Thermal imaging was not possible in two patients due to lack of patient co-operation. There was no differ-

ence in result in patients examined by both liquid crystal thermography and I-R thermography. Thermogra-

phy was normal in 374 patients out of 1,000 (37.4%) i.e. no increased skin temperature or loss of the nor-

mal temperature gradient was demonstrated in the lower limb in which DVT was suspected; these examina-

tions were thus negative for DVT and no further investigation was undertaken. There were no cases of

clinically suspected or proven PE on follow-up of these patients.

Of the 624 patients with increased temperature in the lower limb in which DVT was suspected, i.e. positive

thermography, DVT was confirmed by venography and/or duplex Doppler ultrasound in 297 (47.6%), ex-

cluded in 211 (33.8%) and no further investigation was possible in 116 (18.6%), due to lack of accessible

veins, patient refusal to undergo venography, unavailability of Doppler ultrasound in the earlier years of

this study, or request for no further investigation to be undertaken by the referring clinician.

DISCUSSION

Thermal imaging avoided the need for further investigation by venography or duplex Doppler ultrasound in

37.4% of patients. Thermal imaging offers considerable financial savings over the more expensive conven-

tional investigations which it has been demonstrated can be avoided in over one third of cases.

By comparison with venography, thermography results in the most significant revenue savings, assessed at

US $26,350 (Canadian $37,230) per 1,000 patients. This potential saving is of great importance to health

providers with cash constraints. Compared with duplex Doppler ultrasound there is less financial saving, as

thermography costs about half as much as Doppler for consumables, but there is considerable saving of

skilled ultrasonographer and equipment time.

Thermography has the advantage of being totally non-invasive and risk-free and quick and easy to perform.

It is suggested that the ideal investigative pathway in clinically suspected DVT should be initial thermogra-

phy, proceeding to Doppler ultrasound only when thermography is positive, and finally proceeding to

venography only after negative or equivocal duplex Doppler ultrasound.

ACKNOWLEDGMENTS

Financial support has kindly been provided by The U.S. Department of Defense Agencies. I am indebted to

Professor E F J Ring, Royal National Hospital for Rheumatic Diseases, Bath, UK, for the provision of an

Aga Thermovision 782 I-R thermal imaging camera.

REFERENCES

1 Benotti JR, Ockene IS, Alpert JS, Dalen JE. The clinical profile of unresolved pulmonary embolism.

Chest 1983;84:669-78.

2. Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting

enough deep vein thrombosis? J R Soc Med 1989;82:203-5.

3. Lea Thomas M. Phlebography of the lower limb. Edinburgh: Churchill Livingstone, 1982.

4. Nicolaides AN, Renton SC. Duplex scanning: the second sight of the vascular surgeon. Eur J Vasc Surg

1990;4:445-7.

5. Mitchell DC, Grasty MS, Stebbings WSL, Nockler IB, Lewars MD, Levison RA et al. Comparison of

duplex ultrasonography and venography in the diagnosis of deep venous thrombosis. B J Surg

1991;78:611- 3.

6. Soulen RL, Lapayowker MS, Tyson RR, Korangy AA. Angiography, ultrasound and thermography in

the study of peripheral vascular disease. Radiology 1972;105:115-9.

7. Gordon YB, Cooke ED, Bowcock SA, Ratky SM, Pilcher MF, Chard T. Non-invasive screening for ve-

nous thromboembolic disease. Br J Haematol 1977;35:505-10.

8. Pochaczevsky R, Pillari G, Feldman F. Liquid crystal contact thermography of deep venous thrombosis.

AJR 1982;138:717-23.

9. Cooke ED, Pilcher MF. Deep vein thrombosis: preclinical diagnosis by thermography. Br J Surg

1974;61:971-8.

10. Stevenson AJM, Moss JG, Kirkpatrick AE. Comparison of temperature profiles (Devetherm) and con-

ventional venography in suspected lower limb thrombosis. Clin Radiol 1990;42:37-9.

DITI has been shown to be useful as a diagnostic tool in the differential diagnosis of neuromusculoskeletal injuries and their prognosis for return to participation and/or competition. Since DITI is noninvasive, risk-free, and totally portable, it is a very practical tool in the clinical setting and may be used in the sports medicine clinic, private practice or the training room to assess injury and make clinical decisions. DITI not only helps confirm a diagnosis, but can be used as a gauge to clinically assess progress and treatment response, as well as a prognostic indicator. DITI is useful for, but not limited to, the diagnosis and evolution of epicondylitis, patellofemoral syndromes, ankle injuries, shin splints, stress fractures, myofascial pain syndromes, spinal pain syndromes, shoulder injuries, foot pain syndromes, and vascular disorders. One of DITI's biggest contributions to sports medicine is in the detection of the posttraumatic pain syndromes of reflex sympathetic dystrophy (complex regional pain syndrome) and sympathetic maintained pain syndromes which can occur after minimal injury. These have traditionally been difficult to diagnose. DITI provides an invaluable window into the autonomic ? sympathetic nervous system, which records via somatocutaneous reflex, the sympathetic response to pain and injury.

The controlling mechanism for thermal emission and dermal microcirculation is the sympathetic nervous system. There is a persistent vasomotor tone in the peripheral arterioles and precapillary sphincters. This tone allows the dermal vessels to stay in a partially constricted state so as to inhibit excess heat loss from a higher core temperature. The autonomic regulation involves synapse of preganglionic sympathetic fibres to postganglionic. The postganglionic fibres travel to vascular structures and modulate alpha receptor function in the dermal microcirculation. When there is increased sympathetic function vasospasm will occur due to further vessel constriction and there will be decreased thermal emission at the cutaneous level. This may occur due to either increased postganglionic fibres function/irritation or hypersensitization of the alpha receptors in the dermal microcirculation allowing increased binding of catecholamines. Increased thermal emission will conversely be seen due to situations of decreased postganglionic function (such as seen in denervation) or alpha receptor blockade (receptor fatigue due to release of vasoactive substances such as substance P) .

Muscle, joint, osseous, ligament and nerve injuries all cause the patient to perceive pain. Pain sensation is carried by afferent stimulation of C-nociceptors. These unmyelinated fibres do have a percentage of sympathetics. Pain is then processed centrally and to the brain via the spinothalamic tracts. The patient may feel pain at the area of injury and at sites distant to the area of injury. This is called referred pain. Much research has been done documenting referred pain in myofascial syndromes and somatic visceral conditions. These referred pain zones are believed to be a somatocutaneous sympathetic response. They work via a common autonomic neural network. The somatosympathetic response can be imaged by DITI. Pain is believed to be a neurogenic and autonomic response to injury. DITI findings have been found to correlate well to the patient's report of painful areas and is well suited for diagnostic purposes in athletic injuries. DITI is not a picture of pain, however it is a picture of autonomic dysfunction which seems to correlate well with regions of pain.

Pain felt at the area of injury is generally seen to be hyperthermic (increased thermal emission) due to decreased sympathetic function and alpha receptor blockade from posttraumatic metabolic by-products such as substance P, kinins, histamines, etc. This could be called a somatocutaneous reflex.

Areas of referred pain are generally seen to be hypothermic (decreased thermal emission) due to increased sympathetic function.

DITI has been recognised as a viable diagnostic tool since 1987 by the AMA council on scientific affairs, the ACA council on Diagnostic Imaging, the Congress of Neurosurgeons in 1988 and in 1990 by the American Academy of Physical Medicine and Rehabilitation.  A number of studies have been done to determine DITI’s interexaminer reliability and validity. A study of DITI in low back pain patients found 96% interobserver reliability. In a study of patients with knee pain, 98% test efficiency and 94% interrater reliability was found.

DITI has good clinical utility, is cost effective, risk-free and provides instantaneous real time imaging. DITI should be used by doctors treating common disorders for diagnostic and assessment purposes. While many doctors do not own diagnostic equipment, most major cities and suburban areas have experienced thermographers that will give the referring doctor access to this useful technology and diagnostic test. Major medical centre hospitals should have a thermal imaging department available for referral, and it is hoped that now medical DITI has become more economic it will allow doctors to maximise their specialist skills through access to this objective test of physiology and ultimately benefit their patients.

Digital Infrared Thermal Imaging (DITI) used for adjunctive Breast Disease Screening Can Enhance Early Detection : “Early detection saves lives”

DITI's role in breast cancer and other breast disorders is one of early detection and monitoring of abnormal physiology and the establishment of risk factors for the development or existence of cancer.  When used adjunctively with other laboratory and outcome assessment tools, the best possible evaluation of breast health is made.

This fifteen-minute non invasive test, is a valuable adjunctive tool for alerting gynecologists and primary care physicians to the possibility of underlying breast disease. This test is designed to improve chances for detection of fast-growing, active tumors in the intervals between mammographic screenings or when mammography is not indicated by screening guidelines for women under 50 years of age.

DITI may be especially appropriate for younger women under 50 whose denser breast tissue makes it more difficult for mammography to pick up suspicious lesions. This test can provide a 'clinical marker' to the physician just before clinical breast examination as well as to the mammographer before the mammogram is performed, that a specific area of the breast needs particularly close examination."

Breast cancers tend to grow significantly faster in younger women under age 50.  The faster a malignant tumor grows, the more heat it generates. For younger women in particular, results from DITI screening can lead to earlier detection and ultimately, longer life. 

More than 90 percent of women diagnosed with early stage, localized cancer are alive five years later, yet only 58% of cancers are diagnosed at this stage according to the American Cancer Society.

During a clinical breast examination, a physician must rely on fingers (or palpation) and eyesight to detect tumors in the breast, which for women under age 50 may often occur when cancer is no longer localized or confined to the breast. DITI screening can provide an alert before clinical breast exam or referral to mammography, Sonography, or.  MRI so as to enhance early detection by the physician.

DITI is indicated for women of all ages, particularly in the age group 30 - 50 and women of any age in a high risk group.

Examination recall is dependant on Thermogram result, age, previous history and risk group and can be 3 monthly, 6 monthly, or 12 monthly.

AGE AVERAGE TUMOR DOUBLING TIME

• Under 50 80 Days
• Age 50 - 70 157 Days
• Over Age 70 188 days

DITI of the breast offers the opportunity of earlier detection of breast disease than has been possible with breast self examination, physician palpation, or mammography alone.

DITI is a non invasive test. This means that there is no contact with the body of any kind, no radiation and the procedure is painless.

DITI is performed using sophisticated medical infra-red cameras, a clinician simply captures infra-red images, or “thermograms” of the breasts. The digitized images are stored on a computer and can be sent electronically to a central data-base where a physician, such as a Radiologist or Thermologist (thermal imaging specialist), can perform statistical analysis. Significant asymmetries of the breast can indicate a physiological abnormality. This may be pathological (a disease) or it might indicate an anatomical variant.  When a Thermogram is positive, the job of differential diagnosis begins.  Reports are colour printed and sent to the patients physician / specialist.

DITI detects the subtle physiologic changes that accompany breast pathology, whether it is cancer, fibrocystic disease, an infection or a vascular disease, then the physician can plan accordingly and lay out a careful clinical program to further diagnose and or MONITOR the patient until other standard testing becomes positive, thus allowing for the earliest possible treatment. 

If a suspicious (positive) DITI breast examination is performed, the appropriate follow-up diagnostic and. clinical testing can be ordered. This would include mammography and other imaging tests, clinical laboratory procedures, and nutritional and lifestyle evaluation. 

All patients thermograms (breast images) are kept on record and form a baseline for all future routine evaluations.

DITI is a very sensitive and objective physiological test of abnormalities in the breast and as such is an extremely valuable and important adjunctive test with regard to early detection of breast disease.

Breast cancer is the most common form of cancer among Australian women between the ages of 30 and 60. The average woman has 1 chance in 9 (or about 11 percent) of developing breast cancer during her lifetime. Two-thirds of these women will be over 50 years old, but breast cancer can and does occur in younger women (about 1% of breast cancer cases occure in men).

It takes years for a tumor to grow.

The earliest possible indication of abnormality is needed to allow for the earliest possible treatment and intervention. Evidence of disease must be detected long before the intervention stage has passed.

Doctors do not yet know how to prevent breast cancer. 

You can increase your chances of detecting breast cancer in its earliest stages by understanding the need for, and participating in an early detection programme that will help you increase your chances of detecting breast cancer in its earliest stages.  Only about 20 percent of biopsied breast lumps are cancerous. And, if cancer is found early, there are choices for treatment. With prompt treatment, the outlook is good. In fact, most women treated for early breast cancer will be free from breast cancer for the rest of their lives.

Risk factors

Women who delay having children until their 30’s or who don’t have children at all are at higher risk of developing breast cancer. If you have a mother, sister or relative who has had breast cancer this increases the risk for you as does a personal history of non-malignant cystic breast disease. Women whose periods started before the age of 12 or finished after the age of 50 also incur a greater risk of breast cancer. The link between the contraceptive pill and/or Hormone Replacement Therapy after menopause and breast cancer has not been satisfactorily confirmed or disproved at this stage of scientific research. Finally, if you have suffered from cancer of the womb there appears to be an increased risk of cancer of the breast.

Current Early Detection Guidelines

One day there may be a single method for the early detection of breast cancer. Until then, using a combination of methods will increase your chances of detecting cancer in an early stage.

• Mammography for all women who are age 40 or older.
• Regular DITI screening for women of all ages.
• A regular breast exam by a health professional.
• Monthly breast self-examination.
• Personal alertness for changes in the breasts.
• Readiness to discuss quickly any such changes with a doctor.

These guidelines should be considered along with your background and medical history.

These guidelines may change as new scientific information becomes available. The final decision regarding all tests, of course, should be made on an individual basis.

MAMMOGRAPHY is essential to detecting breast cancer at its earliest stage.  Beginning at age 40, all women should be encouraged to have a mammogram every 1 to 2 years until age 50. After 50, mammography should be done annually.  A mammogram is an x-ray of the breast. It can reveal tumors too small to be felt and can show other changes in the breast that doctors believe may suggest cancer.

In mammography, the breast is pressed between two plates; some pressure is applied to get a clear picture. Usually, two x-rays are taken of each breast, one from the top and one from the side. Although some women are concerned about radiation exposure, the risk is very small.

A doctor also may suggest a mammogram if a symptom of breast cancer is found, whether through Thermography, BSE, the annual exam, or by chance. If you have a symptom of breast cancer, you should not hesitate to have a mammogram if your doctor recommends it.

Other Methods Used For Early Detection

Needle biopsies

Needle biopsies are less physically traumatic than surgical biopsy and leave little or no scarring on the breast. They cost much less than surgical biopsies and can be evaluated faster. Two types of procedures are currently employed. Fine-needle aspiration biopsy,(FNA), requires no anesthesia and offers fast results, sometimes in less than 15 minutes. But FNA requires that a specially trained pathologist be on hand to evaluate the cells removed, and since the technique harvests few cells, it may produce ambiguous results. For those reasons, FNA is most effective for larger lesions that can be felt. The other procedure, core needle biopsy, requires a local anesthetic and takes up to an hour to perform. A spring- loaded "gun" is used to insert the needle into the breast. The physician guides the needle to its target using either mammography or ultrasound. This type of biopsy removes a larger amount of tissue, and results are available in two or three days.

Ultrasound detects breast changes by sending high-frequency sound waves into the breast. The pattern of echoes from these sound waves is converted into an image of the breast's interior. Ultrasound may be helpful in distinguishing between solid masses and cysts (fluid-filled sacs). Unlike mammography, ultrasound cannot detect small calcium deposits that may be present in the breast and that sometimes indicate cancer, nor does it identify small tumors.

Recent technical improvements with ultrasound can often make us more confident in diagnosing benign conditions and can reduce the need for an immediate biopsy.

Magnetic Resonance Imaging (MRI)

An MRI machine can take cross-sectional images through different parts of the body, and may be a very sensitive imaging tool for finding breast cancers. MRI might prove to be better than either mammography or ultrasound in determining the extent of cancer in the breast and where it's located. Breast implants can interfere with conventional mammography MRI is the best tool we have for looking at women with silicone implants. While most diagnostic imaging centers have MRI units, relatively few of them have used the technology for detecting breast cancers. Studies now under way, are evaluating whether MRI should join mammography, thermography and ultrasound as part of a standard regimen.

Digital Mammography

Instead of the image appearing on film, a digital mammogram is stored on a computer disk or tape.  This allows manipulation of the image to increase the contrast. A digital mammogram lends itself to computer-aided diagnosis. Studies are under way at several medical centers. If those trials are successful, digital mammograms may be widely available in about five years.

Diaphanography, or transillumination, shines a bright light through the breast. Transillumination can show the difference between a solid tumor and a cyst. Current studies indicate that this method does not identify the very small cancers that can be detected by mammography. The technique remains experimental.

A Physical Breast Exam Is A Must

Women should have breast examinations during their routine checkups.  You may find it convenient to schedule this exam during your routine physical checkup. If a breast exam is not done during that checkup, you should ask for one. During the exam, the health professional feels the breast and underarm with the fingers, checking for lumps. This is called palpation. The breasts also are checked for other changes such as dimpling, scaling, or puckering of the skin or a discharge from the nipples.  Women 40 and older should have breast examinations annually.

Breast Self Exam (BSE)

Women should do breast self-examination monthly.  Breasts come in all sizes and shapes, just as women do. Your own breasts will even change throughout your life. Your monthly menstrual cycle, menopause, childbirth, breast-feeding, age, weight changes, and birth control pills or other hormones may change the shape, size. and feel of your breasts.  It is important to learn what is normal for you. This can be done by using BSE. It is easy to do, and, as the name implies, you do it yourself. Women taking charge of their own health are doing BSE regularly. They are also eating healthy foods, exercising regularly, and avoiding tobacco use.BSE is done once a month so that you become familiar with the usual appearance and feel of your own breasts. Familiarity makes it easier to notice any changes in your breasts from one month to another. In fact, some health professionals suggest that, at first, women do BSE every day for a month so that they really know the "geography" of their breasts. Early discovery of a change from what is normal is the whole idea behind BSE.

The best time to do BSE is 2 or 3 days after the end of your period, when your breasts are least likely to be tender or swollen.  A woman who no longer has periods may find it helpful to pick a particular day, such as the first day of the month, to remind herself that it is time to do BSE.

If you discover anything unusual, such as a lump, a discharge from the nipple, or dimpling or puckering of the skin, you should see your doctor at once. Remember, 8 out of 10 biopsied breast lumps are not cancer.  Many women have irregular or "lumpy" breasts. The term "benign breast condition" refers to those changes in a woman's breasts that are not cancerous. Many doctors believe that nearly all women have some benign breast changes after age 30. But any change is best diagnosed by your doctor.

Discussing BSE with your doctor will help you understand the procedure better. Ask your doctor or other health professional to review with you the steps of BSE, as well as to explain what you are feeling in your breasts. This will assure you that you are doing your BSE correctly and thoroughly, and you will gain more confidence in examining your breasts.

Remember every part of the breast cancer detection plan:

• Regular Mammograms.
• Regular Digital infrared thermogram screening
• Routine breast examination by a health professional.
• Monthly breast self-examination.

Stand before a mirror. Inspect both breasts for anything unusual such as any discharge from the nipples or puckering, dimpling, or scaling of the skin.  Watching closely in the mirror, clasp your hands behind your head and press your hands forward.  Next, press your hands firmly on your hips and bow slightly toward your mirror as you pull your shoulders and elbows forward.

BREAST SELF-EXAMINATION ( BSE )

REMEMBER, BSE IS NOT A SUBSTITUTE FOR ROUTINE THERMOGRAMS, MAMMOGRAMS OR REGULAR BREAST EXAMS BY A DOCTOR.

Breast self-examination should be done once a month so you become familiar with the usual appearance and feel of your breasts. Familiarity makes it easier to notice any changes in the breast from one month to another. Early discovery of a change from what is "normal" is the main idea behind BSE. The outlook is much better if you detect cancer in an early stage.

If you menstruate, the best time to do BSE is 2 or 3 days after your period ends, when your breasts are least likely to be tender or swollen. If you no longer menstruate, pick a day such as the first day of the month, to remind yourself it is time to do BSE.

Here is one way to do BSE:

• Stand before a mirror. Inspect both breasts for anything unusual such as any discharge from the nipples or puckering, dimpling, or scaling of the skin.  Watching closely in the mirror, clasp your hands behind your head and press your hands forward.  Next, press your hands firmly on your hips and bow slightly toward your mirror as you pull your shoulders and elbows forward.

The next two steps are designed to emphasize any change in the shape or contour of your breasts. As you do them, you should be able to feel your chest muscles tighten.  Some women do the next part of the exam in the shower because fingers glide over soapy skin, making it easy to concentrate on the texture underneath.

• Raise your left arm. Use three or four fingers of your right hand to explore your left breast firmly, carefully, and thoroughly.  Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circles slowly around the breast.  Gradually work toward the nipple.  Be sure to cover the entire breast.  Pay special attention to the area between the breast and the underarm, including the underarm itself.   Feel for any unusual lump or mass under the skin.  Gently squeeze the nipple and look for a discharge. (If you have any discharge during the month - whether or not it is during BSE - see your doctor.) 

Repeat steps 4 and 5 on your right breast. Steps 4 and 5 should be repeated lying down. 

• Lie flat on your back with your left arm over your head and a pillow or folded towel under your left shoulder. This position flattens the breast and makes it easier to examine. Use the same circular motion described earlier. Repeat the exam on your. right breast.

The earliest sign of breast cancer is a single painless firm to hard lump. The edges of the lump are not sharp and stretch out gradually into the surrounding tissue if felt between the fingers. Erosion of the nipple or discharge may indicate an early cancer. Late signs of cancer include an inability to move the lump which appears attached to the skin or to the deeper breast tissue. There may be puckering of the skin above the cancer or retraction of the nipple. Eventually there will be breast enlargement, hardness, inflammation and pain. Almost half of breast cancers begin in the nipple or outer and upper quarter of the breast. The earlier a cancer of the breast is discovered, the better the chances of a complete recovery.

Can Angiogenesis Detect Early Breast Cancer?

While the prognostic significance of tumor angiogenesis remains a topic of intense interest and study, a California radiologist is waging a

largely unnoticed campaign to promote neovascularity as a diagnostic marker for early stage breast cancer.

Dr. Parvis Gamagami

Certain types of vascular formations often precede the appearance of breast tumors on mammography, sometimes by more than a decade,

said Parvis Gamagami, M.D., a radiologist at the Breast Center in Van Nuys, Calif.

Specifically, he cited hypervascularity, enlarged or engorged arteries, and calcified arteries as vascular markers that he and colleagues at

the center have used to identify breast cancers smaller than 5 mm. Of these, the best marker is calcification in the artery, Gamagami said.

At the San Antonio Breast Cancer Symposium in December, Gamagami reported findings from a retrospective review of mammograms

made up to 13 years before breast cancer diagnosis. Among 204 patients, cancer- associated angiogenesis preceded more than 90% of

nonpalpable tumors and 100% of the palpable lesions.

Gamagami's report represented the first major attempt at public discussion of angiogenesis' diagnostic potential in breast cancer. Gama-

gami and his colleagues will publish their first paper on the subject later this year in the Breast Journal. The radiologist has also begun

work on a text that will review evidence collected over the past 15 years.

Authorities on tumor angiogenesis and breast cancer diagnosis say they are unaware of any other reports on the diagnostic potential of

neovascularity.

By Gamagami's admission, the San Antonio presentation swayed few if any opinions. "If you don't have experience with something," he

said, "you don't know what questions to ask."

On the basis of laboratory and clinical observations, the Van Nuys group believes that mammographically detectable breast cancer angio-

genesis evolves in two stages: Preneoplastic cells secrete angiogenic factors that stimulate dormant blood vessels, which increase in num-

ber and size, and then a malignant lesion forms its own nutrient and drainage vessels. Over the course of time, contiguous calcifications

that envelop the nutrient artery help distinguish the vessel from the drainage vein on mammography.

Before It's Visible

"Our work has demonstrated that these neovascular formations appear on mammography before the tumor is even visible," said Gama-

gami, although most physicians, he believes, overlook the formations or dismiss them as normal asymmetry. "What you don't know

about, you don't look for."

Neovascularity may have played a role in the rise and fall of thermography's potential as a breast cancer diagnostic tool. The California

group has found evidence that tumor angiogenesis causes mammographic "hot spots" in the affected breast even in the absence of recog-

nized signs of developing cancer. The investigators have begun a clinical evaluation of the feasibility of performing thermography-guided

biopsies.

"Thermography was eliminated from the diagnostic arsenal because the findings did not correlate with clinical findings, physical exami-

nation, and mammography," said Gamagami. "Everyone concluded that thermography had a high rate of false-positives. Now we know

the reason for those false-positive findings: angiogenesis."

Outside the Van Nuys clinic, other cancer specialists remain skeptical about the diagnostic potential of angiogenesis. San Antonio radi-

ologist Pam Otto, M.D., who saw the poster at the breast cancer symposium, questions the sensitivity and specificity of the approach.

"If you're talking about arterial circulation, that's microscopic and I think it will be very hard to see on mammography," said Otto, an as-

sistant professor of radiology at the University of Texas Health Science Center in San Antonio.

Houston breast imaging specialist Carol Stelling, M.D., is unfamiliar with the work but questions its diagnostic value.

"To take out a [mammographically] busy breast and pick out a vascular pattern seems a little pie in the sky to me," said Stelling, head of

breast imaging at the University of Texas M. D. Anderson Cancer Center in Houston. "I'm not saying that it's not possible, but how we

position the breast and other factors can affect the view.

"Theoretically, we're looking at cellular changes and very small foci," Stelling continued. "For that to be reflected in a major change in an

artery at a very early time frame seems unlikely. In theory, it doesn't seem like it would be necessary for the blood supply to change with

the earliest, very small tumors."

Dr. Judah Folkman

Tumor angiogenesis authority Judah Folkman, M.D., of Harvard University, Boston, also is unaware of any reported findings involving

the diagnostic potential of angiogenesis, but he would welcome such a development.

"If they have indeed found something, that would be neat because I don't know of anyone else who has done that," said Folk-

man, the Julia Dyckman Andrus Professor of Pediatric Surgery. "We keep a running literature search of the whole field [of an-

giogenesis], and I don't recall having seen anything on diagnosis."

He adds that the group will likely face a questioning, skeptical oncology community until the investigators have a large, pro-

spective patient series to validate their findings.

"If they have only one abstract and no formal papers with statistical validation, I would suspect that the work will really be at-

tacked," he said. "That doesn't mean it's not true, but people tend to be really skeptical because there is such a big potential for

false-positive findings."

Gamagami and colleagues are no strangers to skepticism. "But before people decide this is right or wrong, I would just ask that

they look at what we have done and talk to someone who has been working in this area for 15 years," said Gamagami.

"Eighty percent of the breast cancer patients who come to us already have a palpable mass," he explained. "Only 20% have a

nonpalpable mass. If we could have an effect on the 80%, then we could have a real impact on breast cancer mortality."

-- Charles Bankhead