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Ladies' Home Journal has a rich and impressive history of health-advocacy journalism that dates back more than a century, having helped to spur the eventual formation of the Food and Drug Administration, put an end to bogus medications, and break the taboo of silence about sexually transmitted diseases. More recently we have worked with you, our readers, to support legislation to make produce safer, stop ERs from being closed, and improve care in nursing homes.
That's why it's natural and right that we are launching our first annual Health Breakthrough Awards, which recognize doctors and medical researchers who are making lifesaving and life-enhancing discoveries in research, diagnostics, and treatment that we -- patients and medical consumers -- can benefit from right now. We conducted a formal search for candidates across the country, consulting with premier medical schools and organizations, teaching hospitals, foundations, and government agencies. Our winners were chosen from a starting list of nearly 100 amazingly gifted and dedicated health professionals who have transformed their areas of specialty in groundbreaking and long-lasting ways that will improve the lives of millions for generations to come.
One scientist who has made a lasting difference is Ladies' Home Journal's own medical adviser, a pioneer in a new field of research that focuses on the differences between women and men. In her honor we are also launching the Marianne J. Legato Gender-Specific Medicine Award and presenting the first one to her.
When the FDA approved digital mammography in 2000, it was hailed as a breakthrough technology. It allows radiologists to manipulate images of breast tissue, adjust contrast, and zoom in on suspicious areas, possibly eliminating the need for repeat mammograms. Another plus: A digital mammogram requires less radiation than film, can easily be stored electronically (reducing the need to store bulky files with records of breast film) and can be sent quickly to another doctor for a second opinion.
But an important question needed to be addressed: Are digital tests as reliable as film mammograms, which have been used for 35 years and have significantly reduced breast-cancer deaths? The person who answered the question is Etta D. Pisano, MD, director of the University of North Carolina Biomedical Research Imaging Center, in Chapel Hill.
In 2001 -- after 14 years of laying the groundwork (finalizing the test protocol, for example) -- Dr. Pisano launched an estimated $26 million study with the tongue-twisting name of Digital Mammographic Imaging Screening Trial, nicknamed DMIST. The study, focused on nearly 43,000 women, was conducted under her direction by the American College of Radiology Imaging Network (digital breast-screening technology became available experimentally in 1992). In a way, she had been preparing for the study since her mother died of a brain tumor when Dr. Pisano, the eldest of seven kids, was just 15. "I decided at a very young age that I wanted to help other families avoid what I had experienced as much as I could," she says.
The verdict? Both types of mammography have similar rates of accuracy overall, but digital has an edge in finding breast cancer in women under age 50, women who are premenopausal or perimenopausal, and those whose dense tissue makes their breasts difficult to screen with film mammography. Another plus: Many of the small tumors digital technology finds in these women are the ones that need to be caught early. So while experts still don't know whether digital mammography will save lives in the same way that the film method does, it looks promising.
"Finding tumors when they're small is the single most important contribution we can make to a woman's chance of being cured of breast cancer," says Robert A. Smith, PhD, director of cancer screening for the American Cancer Society. "Digital mammography is effective in finding small breast cancers, and recent research results suggest that it may offer an advantage in certain subgroups of women."
Dr. Pisano heeds her own findings: As befits someone under 50, her last two annual mammograms were digital. (Her previous mammograms, which she started having at age 40, were film.) But by no means should a woman forgo having regular mammograms just because she doesn't have access to equipment that provides the digital variety, she insists.
"Women need to get whatever kind of mammogram they can," Dr. Pisano says. Digital machines are still harder to find than film machines -- only about 8 percent of U.S. facilities had them in 2005, according to the American College of Radiology and the New England Journal of Medicine. In addition, the procedure is costlier and may not be covered by insurance. Women in the groups that may benefit particularly from digital mammograms should point this out to their insurance providers, if necessary.
Dr. Pisano's work on digital mammography is far from finished. She and her colleagues are now trying to learn why digital seems to do a better job than film at spotting tumors in certain women. And she is optimistic that even better screening tools will be developed.
"I am certainly going to continue to work in this area," says Dr. Pisano, who is also vice dean of academic affairs at the University of North Carolina School of Medicine (also in Chapel Hill). "We're hoping to develop new tools that require less compression or no compression. I would even like to find a way to prevent breast cancer so we don't have to screen for it."
For Beth Nash, of Bridgewater, New Jersey, Tuesday, July 29, 2003, started like any other day. The then-37-year-old was working as a research nurse in clinical trials at a New Jersey pharmaceutical company. She had had lunch with a friend, sharing stories and laughing. But by 5 p.m. she had developed a splitting headache and collapsed. She was rushed to a nearby hospital, where doctors discerned the grim news: Beth had suffered a hemorrhagic stroke. The clot in her brain was enormous.
She was hospitalized for 21 months and unable to utter a word for the first five. Her hands curled in, a common occurrence after a stroke. She grew additional bone in her left elbow (a side effect of brain injury) that made it impossible for her to straighten her arm. When she tried to stand, her right heel would go up and her toes would curl under. Three orthopedic surgeons were unable to help.
Then a doctor who made what Nash would come to believe were miraculous changes entered her life: Mary Ann E. Keenan, MD, chief of the neuroorthopedic program at the University of Pennsylvania, in Philadelphia. Dr. Keenan is a pioneer in the field of neuroorthopedics. She performs painstaking surgery on bones, muscles, and tendons to straighten hands, arms, feet, and legs that are curled up or under or twisted by stroke and other neurological conditions. She also develops ways to manipulate tendons and muscles so a person can reach for a cup or bend a knee again. She has even figured out how to perform this surgery with smaller, less-painful incisions.
She does not perform miracles, Dr. Keenan insists. It's a matter of understanding that when an injured brain doesn't let a person's joints and limbs function normally, surgical techniques can be used to work around it.
"It's a simple mechanical approach," Dr. Keenan says. "You ask yourself, 'Is this a muscle whose use I should eliminate or can I redirect its force?'
"Maybe a muscle that used to straighten a knee will now bend the knee or a muscle that turned a foot inward can be forced to turn it outward. You can make a muscle do anything." And by removing abnormal bone or lengthening a patient's tendon or muscle, she can extend a joint's range of motion.
"It is startling that you can improve a patient's function not by changing the brain but by changing the limbs," says Nathaniel H. Mayer, MD, director of the Drucker Brain Injury Center at MossRehab, in Elkins Park, Pennsylvania, who sends many patients to Dr. Keenan and works with many of her patients after their surgeries have been completed. Regaining full or even partial use of one or more limbs "gives people a second chance at life and gives them hope," he says.
Dr. Keenan's patients are grateful but perplexed that more doctors don't perform the surgery. "The most common remark I hear is, 'Why didn't someone send me to you before?'" she says.
And it's never too late, even if the brain injury occurred long ago. "The beauty of this surgery is that you can do it as early as six months after a stroke or brain injury -- which allows the brain time to start recovering -- or you can do it 15 or 20 years later," says Dr. Keenan, who operates on 230 people and performs up to 700 procedures in a typical year. The longer you wait to tackle the problem, however, the more aggressive the surgery needs to be.
Over the years Dr. Keenan, who also treats adults with physical problems caused by childhood polio, has become good friends with many of her patients. Knowing that someone has been able to walk his daughter down the aisle is one of the rewards.
One patient from North Philadelphia rode the bus to the hospital on the first anniversary of the day that she was able to lift a cup to thank Dr. Keenan for doing the surgery that made it possible. And a young man who had been injured in an automobile accident and frozen in a fetal position -- and had had 14 surgeries -- surprised Dr. Keenan by walking into her office just before Christmas one year.
Helping Beth Nash, Dr. Keenan says, was a matter of setting priorities. "Beth was in very tough shape," recalls Dr. Keenan. "She had problems in all four limbs. But I knew which ones I could fix."
Dr. Keenan's optimism is what convinced Nash to undergo surgery on her left arm and hand. When she awoke from the operation, her arm was straight and her fingers were less curled.
Since then Dr. Keenan has performed surgeries to relax Nash's right hand, uncurl her right toes and fix her right leg so the heel no longer lifts when she stands. She can now walk with the help of a cane or a wheeled walker and she can write her name.
"Dr. Keenan is as kind and caring as she is competent," says Catherine Nash, Beth's mother. Beth, who still has more surgeries and a long recovery ahead of her, simply says: "She is a beautiful person and a great surgeon, and I will always remember her."
This year marks the 30th anniversary of the most wide-ranging -- and one of the most important -- health research projects ever: the Nurses' Health Study, an ongoing look at the risk factors for major chronic diseases in women and the longest-running study of its kind to focus on women.
Even if you don't recognize the study's name, chances are you've benefited from its findings. Under the guidance of Frank E. Speizer, MD, and his co-researcher, Walter C. Willett, MD, hundreds of papers on women's health have been published in leading medical journals over the past three decades. When it began, "most research had been done on men," says Dr. Willett. "There was a void of information about women."
How do we know that smoking causes heart disease in women? Thank the Nurses' Health Study. Just how healthy is walking? The NHS found that regular walking can stave off heart disease and keep you mentally sharp as you age. It was even ahead of the curve in documenting the harmful effects of trans fatty acids -- now the amount a food contains must be listed on food labels. "Virtually every American is eating differently this year because of our studies," says Dr. Willett, coauthor with Mollie Katzen of Eat, Drink & Weigh Less.
"I don't think I realized how successful it would become," says Dr. Speizer. "But there are more and more health events occurring among these women as they get older. We have 30-plus years of data; the information becomes more valuable as time goes on."
There are actually two Nurses' Health Studies. The original project (NHS I, for short) was established in 1976 by Dr. Speizer, currently the Edward H. Kass Professor of Medicine at Harvard Medical School and senior physician at the Channing Laboratory at Brigham and Women's Hospital, in Boston. NHS I consists of 121,700 married nurses who were ages 30 to 55 when the study began. Its original purpose was to see whether taking oral contraceptives affected a woman's health. (NHS I was the study that found that the pill increases breast-cancer risk modestly, an effect that goes away once you stop taking it.)
In 1989 Dr. Willett, now professor of epidemiology and nutrition at the Harvard School of Public Health, started the Nurses' Health Study II (NHS II) to further study oral contraceptives in a younger group of women as well as to look at how their diet and lifestyle habits affected their risk for disease. He's following 116,686 married nurses, who were 25 to 42 when NHS II began.
Why nurses? "We knew they would be highly motivated and would provide high-quality information about issues such as diagnoses and medications," says Dr. Willett. They were right: Every two years the nurses receive a questionnaire with assorted health questions, and the return rate has remained steady at 90 percent. The nurses have also sent in toenail clippings, blood samples, and cheek cell swabs, enabling researchers to examine hormone and nutrient levels and genetic markers for disease.
"It is an amazing sisterhood," says Carol Fout-Zignani, 50. When she joined NHS II in 1989 -- since then "I've been married, divorced, and married again" -- she had no idea it would be going strong nearly two decades later. "You really feel you're giving back by providing accurate information," says Fout-Zignani, director of continuing medical education at Norton Healthcare, in Louisville, Kentucky.
Both men credit the legions of physicians, researchers, doctoral students, programmers, and research assistants who help oversee the studies, crunch the numbers, and process the findings. Not to mention the nurses: "They have been committed for a very long time and that's what makes the study go," says Dr. Speizer, who stays involved but has passed the baton of principal investigator of NHS I to a colleague.
NHS recently received enough government funding to keep it afloat for at least five more years. And though some 19,000 nurses from NHS I have died -- they are passing away at a rate of three to four a day -- the study continues to be a rich source of health information. As the women of NHS I grow older, watch for a flurry of reports on healthy aging, cognitive function, and Parkinson's disease. Dr. Willett, who studied the mothers of nurses in NHS II, is now studying their sons and daughters.
"NHS is a landmark study," says Vivian Pinn, MD, director of the Office of Research on Women's Health at the National Institutes of Health. "The researchers started it and got women involved many years before attention was paid to women's health beyond the reproductive system and before women's health became part of our national consciousness. It is unique and important."
Ovarian cancer is one of the deadliest forms of cancer and one of the hardest to detect in its earliest stages, since there is no reliable screening test. This year an estimated 20,180 women will learn they have ovarian cancer and some 15,310 women will die of it. Eighty percent of cases aren't diagnosed until the cancer has spread beyond the ovaries.
That's what happened to Kathleen Finn, a mother of three teenagers in Shelburne, Vermont, who learned that she had stage-3 ovarian cancer nine years ago, when she was 42. Her doctor gave her what was then an old but seldom-used treatment for advanced ovarian cancer called intraperitoneal, or IP, therapy, which involves pumping chemotherapy drugs directly into the abdominal cavity in combination with standard intravenous chemo for ovarian cancer.
The treatment was grueling: Finn had a hysterectomy and lost her appendix, a third of her colon, and most of her rectum. She had IP and the drug Taxol a total of six times: every three weeks for five months. Her side effects included fatigue, tingling in her fingers and toes, and ringing in her ears, the last of which persists to this day. But after just two rounds of IP therapy, her levels of a protein that is a red flag for ovarian cancer had plummeted. "I didn't look back," says Finn, who is cancer-free today.
Though Finn didn't know it at that time ("I assumed this is what you did for ovarian cancer," she says), the evidence in favor of IP therapy was unclear. Then, this January, a new study directed by Deborah K. Armstrong, MD, associate professor of oncology, gynecology, and obstetrics at the Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins School of Medicine, in Baltimore, took the cancer establishment by storm by proving that IP therapy can add nearly 16 months to the life of a woman with advanced ovarian cancer and possibly even cure the disease.IP Therapy
Dr. Armstrong's findings, published in the New England Journal of Medicine, were so stunning that, in an unusual move, the National Cancer Institute (NCI) was prompted by her work and other studies to post an advisory on its Web site encouraging doctors to discuss the therapy with their ovarian-cancer patients. "This is the most exciting news since the introduction of Taxol more than 10 years ago," says Edward Trimble, MD, head of gynecologic cancer therapeutics at the NCI.
Dr. Armstrong is a member of the nonprofit Gynecologic Oncology Group (GOG), a nationwide network of cancer specialists who have banded together to improve the treatment of gynecologic malignancies. She first proposed that the group revisit IP therapy in 1996.
"While the regimen had been fairly extensively tested," Dr. Armstrong says, "the data were confusing. I was taking care of women with ovarian cancer and I wanted to find a more effective way to treat them."
Another reason IP therapy hadn't been on the front burner is that it's difficult for both doctor and patient. Because advanced ovarian cancer has already spread beyond the ovary, the treatment requires extensive surgery to remove as much of the tumor as possible before the targeted chemotherapy can begin. Medical staff need special training.
In addition, the patient -- who must be admitted to the hospital, clinic, or chemotherapy center for treatment -- needs to be closely monitored. IP has serious side effects that can be difficult to tolerate, including nausea, abdominal pain, nerve problems in the hands and feet, and kidney problems.
The study finally began in March 1998 and ran until June 2001: GOG colleagues at 40 institutions around the country participated, along with 415 women who had been diagnosed with stage-3 ovarian cancer. Unlike previous studies of IP treatment, Dr. Armstrong's results were clear and definitive.
"It's the first major study to show more than a five-year survival in women with ovarian cancer," says Judith Wolf, MD, chairwoman of the medical advisory board of the National Ovarian Cancer Coalition. The average survival rate for a woman who has advanced ovarian cancer is just over four years.
Although not everyone may respond to IP treatment, Dr. Armstrong's study offers hope to thousands of women.
"It's a step forward," says Dr. Armstrong. "We'd all like to be out of a job by figuring out how to prevent this disease or to diagnose it early when it's curable with surgery alone. Until that time comes, we try to move forward.
"Oncology is a field in which things are changing rapidly. The way we treat patients five or 10 years from now is clearly going to be different from the way we treat patients today," Dr. Armstrong says. "In academic medicine, I can look for some of those advances. That's what lights my fire and makes me come to work each day."
It has been 25 years since HIV was identified, and women now account for 27 percent of all Americans infected with it, according to the Centers for Disease Control and Prevention. But now HIV is spreading among older Americans, and thanks to effective medications, existing women patients are getting older: Women 45 and older make up 24 percent of females diagnosed with HIV in the 33 states reporting HIV/AIDS numbers from 2001 to 2004. They are entering uncharted territory: Doctors know very little about how the virus interacts with the hormonal upheavals of perimenopause and menopause.
Because of Susan Cu-Uvin, MD, professor of obstetrics/gynecology and medicine at Brown Medical School, in Providence, Rhode Island, that may change. In 2004 she founded what is believed to be the only HIV menopause clinic in the United States. "I worried about my female patients who were also in our regular HIV program. As they got older they would ask, 'Will menopause be worse for me than for someone who doesn't have HIV?' We couldn't find any information on this subject. I didn't know what to tell them," she says, explaining how the clinic originated. It now serves 145 HIV-positive women from Rhode Island and Massachusetts, age 40 and older, and will follow them, and future patients, for life.
Though Dr. Cu-Uvin's primary goal is to keep her patients healthy, she's also accumulating information on the special health concerns facing menopausal women with HIV. "We are collecting preliminary data about this special population so that we can request funding for a long-term study," says Dr. Cu-Uvin, who is currently principal investigator for a government-funded study on antiretroviral therapy and HIV in women's genital tracts. She won the 2005 Constance B. Wofsy Women's Health Investigator Award from the AIDS Clinical Trials Group, in Silver Spring, Maryland, for her research on HIV-infected women.
According to Dr. Cu-Uvin, health challenges multiply when an HIV-positive woman reaches perimenopause or menopause. HIV medications can boost the risk of bone loss, diabetes, and heart disease, which can also occur with aging. And scientists have yet to determine whether women with HIV will have earlier onset of menopause or more severe symptoms compared with HIV-negative women.
Dr. Cu-Uvin's commitment to helping women infected with HIV began in her native Philippines when she was doing her training in obstetrics/gynecology and a flight attendant who had the virus asked Dr. Cu-Uvin to be her doctor. "I realized that women with HIV were going to land in my clinic whether I liked it or not and that I was going to have to learn how to deal with it," says Dr. Cu-Uvin, who is also director of the Immunology Center at Miriam Hospital, which is affiliated with Brown University.
On the first Thursday of each month clinic patients can meet with Dr. Cu-Uvin as well as with an infectious disease specialist or an endocrinologist/bone specialist. During a woman's initial visit, doctors take a detailed medical history, assess heart-disease risk and make sure she has had a recent Pap smear, mammogram, and bone-density test.
If a woman is diagnosed with, say, osteoporosis, she will be prescribed medication and monitored. "We want to know the side effects of osteoporosis or diabetes medications on a woman with HIV," says Dr. Cu-Uvin, "whether or not it is working, and whether a patient is actually taking it."
"If you are a woman who has been living with HIV for many years, you need a place where you can get comprehensive care," says Kenneth H. Mayer, MD, professor of medicine and community health at Brown and an infectious disease specialist at Miriam Hospital. Many women with HIV have complicated or busy lives, so access to what he calls "one-stop shopping" for healthcare ensures that they will get the checkups and medications they need.
Dr. Cu-Uvin has become attached to her patients, many of whom have lived to be grandmothers, thanks to antiretroviral drugs, when they never thought they could. "My patients are wonderful, delightful women who give me much joy," she says. They also help her keep things in perspective. "My problems seem so inconsequential compared to what my patients are going through."
Cardiovascular disease kills more American women than men. Osteoporosis affects women disproportionately. But there are more miscarriages of male fetuses compared with female fetuses, and men have less-vigorous immune systems than women. Clearly, a one-size-fits-all approach to patients is not in the best interests of women or men.
Thanks to the formidable efforts of Marianne J. Legato, MD, the medical world has embraced gender-specific medicine, which encourages doctors and researchers to recognize that biological differences affect women's and men's risk for diseases, their experience of them, and their treatment. "Many doctors resist the notion that men and women are different enough that it warrants significant changes in how we practice medicine," says Dr. Legato, founder and director of the Partnership for Gender-Specific Medicine at Columbia University, and more recently the independent Foundation for Gender-Specific Medicine, both in New York City. "But we are different in every system of the body, from our brains to our skin."
This is cutting-edge thinking. But Dr. Legato has always been a trailblazer. After graduating from New York University Medical School, in 1962, she won the Martha Lyon Slater Fellowship in Cardiology, awarded by the American Heart Association (AHA). "I was one of the first people ever to look at the human heart cell in the electron microscope," she says. Long before the AHA's Go Red for Women campaign, Dr. Legato suspected that heart disease in women didn't look or act like heart disease in men. In 1992 she published a landmark book on women and coronary artery disease, The Female Heart: The Truth About Women and Heart Disease, which won the AHA's Blakeslee Award for the year's best book on heart disease written for laypeople.
"Marianne Legato has really been a pioneer in the field of women's health and healthcare," says Vivian Pinn, MD, director of the NIH's Office of Research on Women's Health. "She was one of the first people to talk about the differences in heart disease between men and women."
While traveling the country to promote The Female Heart, Dr. Legato listened to women discuss their experiences. "I was amazed at how little we knew about women's bodies and hearts, and at how angry women were about being misunderstood and even trivialized by the medical profession," she recalls. "If our hearts were that different from those of men, how about the rest of our bodies?" Back at Columbia, she broached the idea of establishing a program that would explore the differences between men and women.Gender-Specific Medicine
In 1997, thanks to her efforts, the Partnership for Gender-Specific Medicine was born. Dr. Legato went on to found Gender Medicine, the partnership's official journal, and recently edited the first medical textbook on the subject. She is also actively building an international gender-specific medicine community. When the 1st World Congress on Gender-Specific Medicine was held in Berlin in February of this year, Dr. Legato was congress president.
"Dr. Legato initiated the congress and has been a catalyst in bringing gender-specific medicine to the attention of the international community," says Kathryn Sandberg, PhD, director of the Center for the Study of Sex Differences in Health, Aging and Disease at Georgetown University, in Washington, D.C. "She has been a pioneer in raising public awareness of gender-specific medicine by making the topic accessible."
Convinced that change in the way we do research and practice medicine often comes when laypeople demand it, Dr. Legato has written numerous books for the general public, including Eve's Rib, What Women Need to Know, and Why Men Never Remember and Women Never Forget.
Dr. Legato urges the public to take the initiative to advance gender-specific medicine. "Women have profited from the risks men took by agreeing to participate in clinical trials," she says. "Now we need to step up and help researchers gain more information about us by direct participation in trials."
Myron L. Weisfeldt, MD, a former Columbia colleague who now chairs the department of medicine at Johns Hopkins University School of Medicine, in Baltimore, says, "She has championed the idea that we ought to speak much more in terms of gender-specific differences within all medical issues rather than about men's health or women's health in isolation. She was ahead of the curve."
Much more remains to be done, Dr. Legato believes: "Without question, things have improved. We now have a very well-educated group of physicians who really do understand the gender-specific experience of heart disease. We are making progress in brain research. But we have a long way to go in other disciplines." Her latest target: more information on men, "who are medically different and in many ways more vulnerable than women to disabling diseases."
Originally published in Ladies' Home Journal, September 2006.