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Colon cancer is the second-deadliest form of cancer after lung cancer. If recent messages about colon cancer screening have left you a little confused, that's understandable. In August, the American College of Physicians (ACP) released updated guidance for colon cancer screening that differs from other major organizations, including recommendations from the American Cancer Society (ACS) and the US Preventive Services Task force (USPSTF).

So, what do you need to know?

How does the advice differ?

First, please note that this advice applies only to people at average risk without a family history of colon cancer. If you have family history, or if other health issues put you at higher-than-average risk for colorectal cancer, talk to your doctor about the best course of action for you.

The main point of disagreement relates to the age at which people should start getting screened. The new ACP guidance says 50, while the other two organizations recommend 45. That earlier age is endorsed by the U.S. Multisociety Task Force on Colorectal Cancer. It's also endorsed by many physicians, including Harvard Medical School professor Dr. Andrew T. Chan, a gastroenterologist and director of epidemiology at Massachusetts General Hospital Cancer Center, who helps explain key facts below.

Why do experts suggest starting screening earlier?

"We're facing an unexplained and alarming increase in the incidence of colon cancer in people younger than 50," says Dr. Chan.

Overall, deaths from colon cancer dropped by 2% per year from 2011 to 2020. But that's not the case among people younger than 50. In that age group, deaths from colon cancer rose between 0.5% and 3% during the same time period, according to statistics published in 2023.

The rising rates of colon cancer in younger people are occurring in all racial and ethnic groups, with the steepest rises seen among Alaskan Natives and Native Americans. Overall, Blacks and African Americans are more likely to get and die from colon cancer than whites, and early-onset cases are higher in Black individuals than whites.

Efforts to encourage colon cancer screening began in the mid-1990s. Today, about 60% of adults over 50 follow the advice to receive a colonoscopy (described below) on a regular basis. This track record, while not perfect, likely explains the decline in deaths from colon cancer in older adults.

"I think that promoting earlier screening will help stem the rise in early-onset cases, at least for those in their 40s. We've also seen that earlier colonoscopies may be associated with lowering incidence of colon cancer even later in life, "says Dr. Chan.

What are the different screening tests for colon cancer?

The two most widely used screening tests are a standard colonoscopy and various stool-based tests.

Colonoscopy. For this test, a gastroenterologist or surgeon snakes a long, flexible tube with a camera on the end through your rectum and beyond to inspect the entire length of your colon. Considered the gold-standard test, this procedure can detect precancerous polyps called adenomas, and allow for their removal.

The test requires taking laxatives and drinking lots of fluids beforehand to clean all the fecal material (stool) out of your colon. Serious complications, which include perforation or bleeding, are rare, occurring in about three in 1,000 procedures. If no polyps are found, a repeat colonoscopy isn't recommended for another 10 years. If you have polyps, or your risk or symptoms change, this interval will be shorter.

Stool tests. The more worrisome colon polyps (adenomas) often shed tiny amounts of blood and abnormal DNA into the stool. This can be detected from samples you collect yourself at home.

• Two tests, the fecal occult blood test (FOBT) and fecal immunochemical test (FIT), check for blood. They require small stool samples that you put on a card or in a tube that's then mailed to a lab. These tests should be done every year.
• A third option, the FIT-DNA test, checks for both blood and abnormal DNA; it's usually repeated every three years.

Additionally, the guidelines from the American College of Physicians suggest another option: flexible sigmoidoscopy, which inspects only the lower part of the colon, once every 10 years, combined with a fecal FIT testing every two years. However, doctors in the United States rarely order sigmoidoscopy today.

If flexible sigmoidoscopy or any of these stool tests show evidence of a problem, a colonoscopy is needed to check for adenomas or cancer.

Why might stool-based screening make sense for younger adults?

Colonoscopy isn't necessarily the best initial screening test for everyone, says Dr. Chan. That's especially true for younger people, mainly because it's time-consuming and inconvenient.

"Maybe you just can't find time in your schedule or are worried about having a colonoscopy," he says. If that's the case, a stool-based test — which is noninvasive and takes very little time — is an appropriate option.

"The worst option is not doing anything, because early detection and treatment can prevent deaths," he says.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

 

There was a time when pediatricians routinely recommended tonsil removal, even for healthy children — including me. As far as I can tell, I suffered no ill effects — plus, I got extra ice cream!

That practice is no longer routine. But it does raise an interesting question: Why do we have body parts that can be safely removed? If they’re not needed, why do humans have them in the first place?

One theory is that these nonessential organs and glands once served important roles in the lives of our evolutionary ancestors but now represent anatomic remnants. For example, it was long thought that the appendix helped our predecessors digest food, but over thousands of years became obsolete. And some organs are supremely useful during certain stages of life, but then become expendable.

Seven (mostly) unnecessary body parts

Here are seven removable parts of the body:

Appendix

This organ is about the size of your little finger and hangs from the lower right side of your colon. For reasons that aren’t clear, this part of the intestinal tract sometimes becomes blocked, infected, or inflamed. Aptly enough, the word appendicitis means inflammation of the appendix. While it may settle down with antibiotic treatment, emergency surgical removal (an appendectomy) is often necessary.

Tonsils

A network of lymph nodes throughout the body is part of the immune surveillance system that helps trap dangerous invaders such as bacteria and viruses. Consider your two tonsils as larger, specialized lymph nodes watching out for these intruders. They are located at the back of the throat just to the sides of and behind the uvula, the dangling piece of tissue above them.

Now, removing the tonsils (a tonsillectomy) is only recommended for people with repeated bouts of bacterial throat infections such as strep throat, a condition common in children. Once removed, other lymphoid tissue, including the actual lymph nodes, can take over the job of the tonsils.

Adenoids

Situated in the back of the nose where the nasal passages meet the mouth and throat, adenoids are similar to tonsils. They can also become inflamed, infected, and swollen. So when the tonsils are removed, the adenoids are generally removed at the same time. The combined procedure is called tonsillectomy and adenoidectomy. As is true for the tonsils, other lymphoid tissue takes over when the adenoids are gone.

Gallbladder

The gallbladder sits just under the liver in the upper right part of the abdomen. It stores bile made in the liver and releases it into the digestive tract when needed to help digest fatty foods. The gallbladder may need to be removed (a cholecystectomy) if it becomes inflamed, a condition called cholecystitis. Most often this occurs due to infection or gallstones, which are a hardened collection of bile. In some cases, rest and antibiotics can control gallbladder inflammation so removal can be delayed or even avoided.

Uterus

This remarkable reproductive organ has a single purpose: to support fetal growth until birth. When necessary, the uterus can generally be removed (hysterectomy) without impairing health. Common reasons for removal include painful or excessive menstruation, benign growths called fibroids that cause pain or bleeding, or cancer.

Thymus gland

This small gland sits high in the upper chest behind the breastbone. In a fetus or newborn, it’s quite important in the development and maturation of the immune system. But adults can live well without it. Surgery to remove the thymus (a thymectomy) may be recommended if the thymus becomes cancerous, or if a person develops the autoimmune condition myasthenia gravis.

Spleen

Like adenoids and tonsils, the spleen is made up of lymphoid tissue. It filters the blood, removing infectious organisms, aging blood cells, and other abnormal cells traveling through the bloodstream. But sometimes the spleen becomes overactive and begins removing healthy cells.

For example, idiopathic thrombocytopenic purpura (ITP) may develop when platelets (clotting blood cells that prevent excessive bleeding) are removed from circulation. With few platelets left in the bloodstream, bruising and bleeding may be life-threatening. Although medications can help, removal of the spleen (a splenectomy) may be necessary. Or sometimes trauma to the spleen, especially after sports injuries and car accidents, causes internal bleeding, which may lead to splenectomy.

People who lack a spleen are more prone to certain infections, so if removal isn’t urgent, a number of vaccinations are recommended before splenectomy.

The bottom line

I’ve heard it said that at least half of all body parts are unnecessary. That’s a myth. But as with most myths, there is some truth to it: there are indeed many body parts that can be safely removed. That said, it’s generally best to avoid unnecessary surgery and keep the parts you were born with if you can.

Sure, you can survive and thrive despite having your appendix removed. But it’s worth keeping in mind that our understanding about so-called spare parts may change over time. The appendix is a good example: researchers have discovered that the appendix may play a role in immune development and stores “good bacteria” to repopulate the gut in case of future illness. And there is evidence that removing the thymus may slightly increase the risk of cancer, autoimmune disorders, and death.

Someday we may discover important functions for other body parts we now consider expendable. And maybe then I’ll wish I had my tonsils back.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

It’s tempting at this time of year to let summer sleep schedules stay in place or let bedtimes slide, especially when parents feel tired out, too. But it’s important that children have a regular routine — and that they are sleeping during the dark hours and awake during the light ones, as our bodies do best that way. That’s true for families who are home-schooling, as well: even when the trip to school is just a walk to the kitchen table, allowing for more sleep than those catching an early bus may get, no child should be spending all morning in bed.

Sleep is crucial for all of us, and this is particularly true for children. Without enough quality sleep, children are more likely to have health and behavioral problems — and difficulty learning.

Here are a few simple things you can do to help your child get the sleep they need.

Have a regular schedule

Our bodies do best when we go to bed and wake up at roughly the same time every day.

• Children and teens need eight to 10 hours of sleep. Count back 10 hours from when your child needs to get up in the morning. That’s roughly the time they need to be getting ready for bed (for younger children, count back 11 hours).
• For example, if your teen needs to be up at 7, then they should be getting ready for bed by 9, and in bed by 10 (since most of us don’t fall asleep the moment our head hits the pillow). A younger child should start getting ready (bathing, etc.) by around 8.
• Understand that teens are biologically wired to fall asleep later and wake up later and will naturally have later bedtimes. Unfortunately, most school districts don’t accommodate to this, so you are often working against biology.
• While it’s okay to stay up a bit later on weekends, don’t let the bedtime vary by more than an hour or so.

Turn off the screens before bed

The blue light emitted by screens can keep us awake.

• It’s best if the screens can be off two hours before you want your child asleep. Use that time when they start getting ready for bed as the time that the screens go off.
• The only real way to achieve this is to get all devices out of the bedroom. (So true!)
• Teens will fight you on this. If you can, hold firm (and buy them an alarm clock if they say they need their phone for this). At the very least, be sure that the phone is on Do Not Disturb mode overnight.

Have an environment that encourages sleep

• Quiet things down. If you are watching TV, turn the volume down, and in general try to not make much noise after children go to bed.
• Consider a white noise machine, or a fan (or air conditioner if you live somewhere warm). There are also white noise apps for those teens who won’t give up their phones.
• Room-darkening curtains can make a difference for children who tend to wake up at the first light of dawn — or who can’t fall asleep if it’s not fully dark outside.

Know how other factors influence sleep

• Busy teens often have difficulty getting everything done in time to get enough sleep. Talk with your teen about their daily schedule and look for ways to help them get more shut-eye, such as getting homework done during the school day, or limiting video games or other activities that eat into homework time. Sleep needs to be the priority.
• Limit caffeine. It’s best not to have any, but certainly nothing from mid-afternoon on.
• Limit naps! For a tired older child naps may seem like a good idea, but they can interfere with nighttime sleep. Naptime is okay through preschool.
• Make sure your child gets exercise. It’s not only important for their health, it helps their sleep.
• Have calming routines before bed (not exercise!).

If your child is having trouble falling asleep, or is waking up at night, talk to your doctor. It’s also important to talk to your doctor if your child is snoring or having other breathing problems at night. Don’t ever ignore a sleep problem; always ask for help.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

If the eyes are the windows to the soul, then consider the tongue a sort of check-engine light for the body. The tongue’s appearance gives doctors an idea about certain aspects of your health, and its color is an important clue.

What should your tongue look like?

The tongue should have a rounded, symmetrical shape. It’s generally light pink, though it may have a little purple or brown pigmentation in African, Asian, and Mediterranean populations. It can also have a hint of white coating.

“The coating comes from a tough protein called keratin, which helps keep your tongue from being scratched when you eat,” says Dr. Tien Jiang, a prosthodontist in the Department of Oral Health Policy and Epidemiology at the Harvard School of Dental Medicine.

Up close, you might be able to see that your tongue is covered in tiny bumps (papillae) that serve several purposes:

• They sense temperature and touch.
• They contain taste buds that enable you to detect if food is sweet, salty, sour, bitter, or savory.
• They create friction to help you form a little ball of food (bolus) that you can swallow.

Can diet affect tongue color?

Yes. Sometimes diet may be partly to blame for a shift away from your usual tongue tone. That’s because the papillae can absorb the colors and residues of foods and drinks you consume. For example, that blue popsicle or candy you ate as a kid probably turned your tongue an exciting shade of azure. Coffee, tea, and many types of foods, such as curried dishes with lots of yellow turmeric, can also leave their marks.

Discoloration is usually just temporary, however. Drinking plenty of water and maintaining good oral hygiene will wash away food and dyes that cling to the tongue.

A dark or bright tongue, white patches, and other causes for concern

Some tongue colors and appearances are signs of health issues. Check with your doctor if you notice any of the following:

• A brown or black tongue signals a condition called “black hairy tongue.” This occurs when papillae get too long. These tiny bumps don’t usually get much chance to grow because they are shed regularly with all the activity in your mouth. If they do grow, they can trap bacteria and a mix of food colors, leading to the brown or black tinge. Risk factors include taking antibiotics or antihistamines, smoking, dry mouth, drinking excessive amounts of coffee or black tea, or poor oral hygiene.
• Thick white patches or white sores on the tongue probably mean you have an overgrowth of yeast in the mouth (thrush). Thrush can be triggered by conditions such as diabetes or HIV, side effects of antibiotics or cancer treatment, wearing dentures, smoking, dry mouth, or using steroid inhalers. In rare cases, white patches or sores are symptoms of oral cancer.
• If your tongue has painful red or yellow sores, you might be dealing with canker sores (irritated tissues), thrush (which can sometimes appear as red patches), or (in rare cases) oral cancer.
• A bright red tongue can indicate that you have a vitamin B12 deficiency or an infection called scarlet fever — a Streptococcus bacteria infection in the throat (strep throat) accompanied by a red body rash. If you have bright red patches that don’t hurt and seem to migrate from one place on the tongue to another, you might have a harmless, incurable condition called “geographic tongue.”

Should you brush your tongue or use a tongue scraper?

Good oral hygiene requires that you floss your teeth at least once a day and brush them at least twice a day. Take a few seconds to use the brush on your tongue.

“Stick out your tongue and swipe your toothbrush from the back of your tongue to the front: one swipe down the middle, one swipe down the left side, and one swipe down the right side. That helps remove bacteria and debris that collect in papillae,” Dr. Jiang says.

Some people swear by using a tongue scraper to clean the tongue. Dr. Jiang isn’t a fan, but doesn’t have a problem with someone using the tool, which is pulled forward on the tongue in a similar fashion to brushing the tongue. “The data about tongue scraper effectiveness are mixed,” she says. “It just comes down to what you’re willing to do daily to keep your tongue, teeth, mouth, and gums as healthy as possible.”

Worried about your tongue? What to do

If you’re worried about anything wrong with your tongue — especially if you also have a fever, a very sore throat, sores that won’t go away, or other new symptoms — call your primary care doctor or dentist.

Your doctor or dentist can

• assess your condition
• prescribe or suggest treatments to relieve discomfort, such as medicated mouthwashes or warm-water rinses
• urge you to stay hydrated and step up your oral hygiene.

If necessary, your doctor can refer you to a specialist for further evaluation.

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Ever see ads for products that promise to supercharge immunity? Activate your body’s natural defenses? Support a healthy immune system while delivering a potent boost derived from nature’s hottest immune-enhancing ingredients?

While the words may change to reflect the latest trends, the claims certainly sound amazing. But do the multitude of products promoted as immune boosters actually work? What steps can we take to support the immune system? Both are important questions, especially in the wake of a deadly pandemic and as flu and cold season arrives.

IV drips, supplements, cleanses, and superfoods

The lineup of immune-boosting products and advice includes:

• Home intravenous (IV) drips. Want a health professional to come to your home with IV fluids containing various vitamins and supplements? That’s available in many US cities, and some companies claim their formula is designed to supercharge immunity. These on-demand IV treatments aren’t risk-free and can be quite expensive.
• Vitamins and supplements. Popular options include turmeric, milk thistle, and echinacea, often in combination with various vitamins. Hundreds of formulations are available.
• Superfoods and foods to avoid. If you search online for “foods to boost the immune system” you’ll see thousands of articles touting blueberries, broccoli, spinach, dark chocolate, and other foods to keep infections away. There’s also a list of foods to avoid, such as sugary drinks or highly processed meats, because they’re supposed to be bad for your immune system.
• Cleanses and detox treatments. No doubt you’ve seen pitches for cleanses and detox products intended to remove toxins from the body. Their marketing warns that the environment is full of harmful substances that get into the body through the air, water, and food, which we need to remove. Advocates suggest that, among other harmful effects, these often unnamed toxins make your immune system sluggish.

Are the heavily marketed IV drips, supplements, or detox products endorsed by the FDA?

No. In fact, the standard disclaimer on supplements’ claims of immune-boosting properties says: “This statement has not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.”

Yet sellers are allowed to use phrases like “boosts immune function” and “supports immune health.” These terms have always seemed vague to me. More importantly, they’re confusing:

• Boosting immunity is what vaccinations do. They prime your immune system to help fight off a specific infectious organism (like the flu shot before each flu season).

• Immune support typically describes vitamins such as vitamin C, or other nutrients necessary for a healthy immune system. It’s true that a deficiency of vital nutrients can cause poor immune function. But that doesn’t mean a person with normal levels of nutrients can expect supplements to improve their immune system.

Can products marketed as immune boosters actually boost immunity?

Unless you have a deficiency in a key nutrient, such as vitamin C or zinc, the short answer is no.

That is, there’s no convincing evidence that any particular product meaningfully improves immune function in healthy people. For example, results of studies looking at various supplements for colds and other similar infections have been mixed at best. Even when taking a particular supplement was linked to reduced severity or duration of an infection like a cold, there’s no proof that the supplement boosted overall immune function.

This goes for individual foods as well. None has ever been shown to improve immune function on its own. It’s the overall quality of your diet, not individual foods, that matters most. A similar approach applies to advice on foods you should avoid, such as sugary drinks or highly processed meats: the best foods to avoid in support of your immune system are the same ones you should be limiting anyway.

How to get the most out of your immune system

It’s not a secret and it’s not a product. What’s good for your overall health is good for immune function. The best ways to keep your immune system at peak performance are:

• Eat well and follow a heart-healthy diet, such as the Mediterranean diet.
• Exercise regularly and maintain a healthy weight.
• Don’t smoke or vape.
• If you drink alcoholic beverages, drink only in moderation.
• Get plenty of sleep.
• Minimize stress.
• Get regular medical care, including routine vaccinations.
• Take measures to prevent infection such as frequent hand washing, avoiding people who might have a contagious illness, and wearing a mask when it’s recommended.

This list probably looks familiar. These measures have long been recommended for overall health, and can do a lot to help many of us.

Certain illnesses — HIV, some cancers, and autoimmune disorders — or their treatments can affect how well the immune system works. So some people may need additional help from medications and therapies, which could truly count as immune boosting.

The bottom line

Perhaps there will come a time when we’ll know how to boost immune function beyond following routine health measures. That’s simply not the case now. Until we know more, I wouldn’t rely on individual foods, detox programs, oral supplements, or on-demand IV drips to keep your immune system healthy, especially when there are far more reliable options.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

RSV, or respiratory syncytial virus, is a common virus that just causes cold symptoms for most people. But for very young babies, and for babies and young children with certain health problems, it can be very dangerous. A new immune-boosting therapy may help.

What complications can RSV cause?

RSV is the leading cause of bronchiolitis and pneumonia in children under a year. It can cause life-threatening problems with breathing, especially in children with heart or lung disease.

Which medications work against RSV?

There aren't any medications that treat RSV effectively. To prevent the illness, a medication called palivizumab (Synagis) can be given as a monthly shot to high-risk infants during RSV season. (While RSV is not always seasonal, many cases occur between late fall and early spring.)

But insurance companies only cover this medication for certain patients, using strict criteria. Its cost and the fact that it has to be given monthly have been barriers to its use.

How can the new RSV shot help?

This year, a new shot could make a big difference. It is called nirsevimab (Beyfortus). Like palivizumab, it is an antibody treatment — but unlike palivizumab, it will be available to all babies under 8 months of age, not just high-risk infants. Here's what to know:

• This is not a vaccine. Vaccines prod the body to make antibodies that help protect against an infection, while this shot works by giving the antibodies directly.
• These antibodies can prevent or lessen the severity of an RSV infection.
• Because the body isn't making its own antibodies the shot does wear off, but the good news is that just one shot can last five months. If given right at the beginning of RSV season, this essentially provides protection for the whole season.

Who can receive the new RSV shot?

One dose of nirsevimab is recommended for all babies under the age of 8 months as close to the start of RSV season as possible. Newborns can get it before they leave the birth hospital, and it can be given along with routine vaccinations.

The new shot is also recommended for children 8 to 19 months with conditions that put them at high risk of becoming very sick if they get RSV. These include

• prematurity
• chronic lung disease
• congenital heart disease
• weakened immune system
• cystic fibrosis
• neuromuscular disorders, or other disorders that make it hard for babies to swallow and clear mucus.

Infants and toddlers who get nirsevimab do not need to get monthly shots of palivizumab as well.

Because this is brand new, there may be some challenges with getting it to all the infants and toddlers that are eligible. Talk to your doctor if your baby or toddler would be eligible this season.

For more information, check out the press releases from the Centers for Disease Control and Prevention and the American Academy of Pediatrics.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

Wriggling toes in the sand and wearing sandals are warm weather treats, unless you’d rather keep your toes under wraps due to thickened, yellowish nails. Nail fungal infections (known as onychomycosis) are common, affecting up to 14% of the general population. In advanced cases, nails can become brittle, crumbly, or ragged, or even separate from the nail bed.

While completely curing these fungal infections is difficult, the right treatments can discourage the problem from spreading and make your nails look better.

Do nail fungal infections only affect toenails?

No, fingernails can become infected, too. However, toenails are a more common target because of certain habits, including wearing shoes, so we’ll concentrate on them in this post.

How do people get toenail fungus?

“Feet are more likely to be sweaty and damp, which provides a better environment for the fungi, yeasts, and molds that are naturally present on your skin to flourish,” says Dr. Abigail Waldman, a dermatologist at Harvard-affiliated Brigham and Women’s Hospital.

People also can be exposed to various fungi, known as dermatophytes, by walking barefoot in locker rooms, spas, or near swimming pools, or getting a pedicure at a nail salon, she says. A fungal overgrowth can infect the area between your toes and the skin or your feet, causing athlete’s foot. The fungus can then spread to the toenails.

What makes toenail fungus hard to treat?

While antifungal creams can easily treat skin infections, toenails are another story.

“Nail tissue is harder and thicker, so these medications don’t penetrate very well,” Dr. Waldman explains. That’s also true for antifungal drugs taken as pills. Toenails grow slowly and the tissue isn’t very metabolically active. So although the medication gets into your bloodstream, only small amounts end up in your toenails. That’s why it’s hard to get rid of toenail fungus once it takes hold.

What counts as a cure?

Research reports so-called clinical cure rates between 60% to 80%, but this means only the absence of symptoms — that is, your toenails return to their normal appearance. The fungal infection may still be lurking under your nails, says Dr. Waldman.

In fact, in clinical trials when investigators recheck toenail clippings for any residual fungus after treatments applied to nails, only around 10% to 15% show no detectable fungal spores. As a result, recurrences of toenail fungal infections are fairly common.

Despite this, there’s a reasonable chance that different treatment approaches can improve your symptoms and the appearance of your toenails.

What works for treating toenail fungus?

Here is a rundown of the different treatment options, starting with Dr. Waldman’s go-to first-line suggestion, which uses inexpensive products you may already have in your home.

Home remedies

Soaking your toes to soften your nails before applying a fungus-fighting agent will help the remedy penetrate the nail. For the soak, Dr. Waldman recommends mixing one part white or apple cider vinegar to three parts warm water. Soak your toes for at least 10 minutes (but up to 40 minutes is better). Instead of vinegar, you can use Listerine, which contains thymol, the main compound in the herb thyme. Like vinegar, thymol has antifungal properties.

Then dry your feet well and apply an antifungal substance to all the affected nails. One option is a paste of crushed garlic, but most people will probably find the over-the-counter drugstore products listed below more convenient to use.

Over-the-counter products

The best evidence is for 100% tea tree oil, but another popular option is Vicks VapoRub (which also contains thymol and other essential oils that may fight fungus), Dr. Waldman says. Or you can use one of the various creams sold to treat athlete’s foot on your toenails.

Be sure to apply the product right after soaking. The clinical cure rates for each of these approaches vary between products, and depend on the severity and duration of the infection. But about 60% of people notice improvements after a few months of treatment, Dr. Waldman says.

Drugstores also carry several other toenail treatments, including a treated patch you put on your nails overnight. It contains urea, an acidic substance that improves the look of your nails by making them less brittle and discolored. Another product that promises similar results uses a tiny LED light that you clip onto your toenail after applying a liquid containing polyethylene glycol, which softens nails.

Prescription treatments to put on toenails

These topical products, which are best for milder infections, include amorolfine (Loceryl, others), efinaconazole (Jublia), tavaborole (Kerydin), and ciclopirox (Penlac). They are clear lacquers that you brush on your toenails once daily, usually for months. It may take as long as a year to see results. Clinical cure rates range from 35% to 60%.

Prescription pills

More severe infections may respond better to oral drugs, which include fluconazole (Diflucan), griseofulvin (Grifulvin), itraconazole (Sporanox), and terbinafine (Lamisil). These are taken daily in pill form for three months. While the clinical cure rates are higher (around 80%), these drugs have more side effects, including stomach upset, diarrhea, and (in rare cases) liver damage.

Laser therapy

Lasers penetrate and break down nail tissue, helping to destroy the fungus. There are many different types of lasers and protocols. Clinical cure rates are hard to pin down, but some have been reported as ranging between 60% and 75%.

Advice on toenail clippers, nail polish, new shoes, and more

During and after treatment, Dr. Waldman advises people to use two sets of toenail clippers — one for infected nails and one for noninfected nails — to prevent fungal spread. If you’re embarrassed by the appearance of your toenails, it’s okay to use nail polish for short periods of time, she says.

Once you finish treatment, buying new shoes will help avoid reinfection. “I also always recommend people do a diluted vinegar soak once or twice a week after finishing treatment, which helps prevent any lingering fungus from reinfecting the nail,” says Dr. Waldman.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

When it comes to limiting side effects from radiation therapy, the name of the game is precision. Doctors want to treat the cancer while avoiding healthy tissues, and fortunately technological advances are making that increasingly possible.

One newer technique called stereotactic body radiotherapy (SBRT) can focus precisely targeted beams of high-dose radiation on a tumor from almost any direction.

The entire course of therapy requires only five individual treatments over two weeks, making SBRT more convenient than earlier low-dose methods that require more visits to the clinic. The treatment relies on specialized types of medical imaging scans that allow doctors to visualize where cancer exists in the body.

Advances in technology

Recently, doctors have begun to integrate SBRT with imaging scans that can visualize a tumor's movements in real time. Simple acts such as breathing, swallowing, or digesting food can shift a tumor's position. But this new technique — which is called magnetic resonance–guided daily adaptive SBRT, or MRg-A-SBRT for short — continually adjusts for those motions, so that doctors can focus more precisely on their targets.

Now, a new study helps to confirm that MRg-A-SBRT has fewer side effects than a related method called CT-SBRT, which uses computed tomography for imaging.

According to the study's lead author, Dr. Jonathan Leeman, a radiation oncologist at Harvard-affiliated Brigham and Women's Hospital in Boston, MRg-A-SBRT offers several advantages over CT-SBRT: one is that doctors using it can adjust treatment plans to account for a tumor's daily motions (this is called adaptive planning). The technology collects multiple MRI images per second during a radiation procedure, thus ensuring accurate real-time targeting. And finally, MRI visualizes the prostate with better resolution.

Analysis of studies

During the new study, Dr. Leeman and his colleagues searched the medical literature for every published clinical trial so far evaluating SBRT for prostate cancer, either with MRI or CT guidance. (This type of study is called a systematic review.)

The team ultimately identified 29 clinical trials that monitored outcomes for a total of over 2,500 patients. Short-term data on side effects was collected for up to three months on average after the procedures were completed.

Leeman's team used statistical methods to pool results from the studies into combined datasets. They found that the MR-SBRT-treated patients had fewer side effects. Specifically, 5% to 33% of men treated with MR-SBRT had genitourinary side effects, compared to between 9% and 47% of men who had the CT-guided treatments. Similarly, the risk of gastrointestinal side effects in the MR-SBRT-treated men ranged from 0% to 8%, compared to between 2% and 23% among men whose treatments were guided by CT.

Conclusions and comments

The authors concluded that "technical advances in precision radiotherapy delivery afforded by MRg-A-SBRT translate to measurable clinical benefit" (i.e., better tolerated treatments). But precisely why the treatments were better tolerated remains unclear. Is it because MR-scanning has better resolution? Did adaptive planning (and real-time targeting) account for the lower risk of side effects, or can that be attributed to some combination of all these factors? Dr. Leeman says that adaptive planning is "likely the main differentiator," but he adds that further studies are needed to confirm where the benefits come from.

To place this important work in perspective, we reached out to the authors of the new paper, as well as Dr. Anthony Zietman and Dr. Nima Aghdam, two Harvard-affiliated radiation oncologists who are also on the editorial board of the Harvard Medical School Annual Report on Prostate Diseases. All these experts feel this new technology has very promising potential.

But both groups cautioned that as with all newly developed innovations, results from additional studies — including clinical trials that are currentlyongoing — will be needed before more widespread uptake of the technology is warranted. Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, says he "agrees with this conservative, yet optimistic assessment."

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

If the first goal of a drug advertisement is to grab your attention, this ad for Entyvio (vedolizumab) works.

You see a young woman getting into her car, sitting in her work cubicle, sitting in a restaurant, and finally in the waiting room of her doctor’s office. But she’s not sitting on the seat of the car or on a chair; in every scene, she’s sitting on the lid of a toilet.

Strange, right?

Why all the toilets?

The voiceover provides a clue: “When you live with moderate or severe Crohn’s disease or ulcerative colitis, your day can be full of reminders of your condition. Never knowing, always wondering.” And there’s another hint: the woman keeps grimacing and clutching her belly.

But these clues may not be enough. What’s never explained in this ad is that abdominal pain and sudden diarrhea are among the most common symptoms of Crohn’s disease and ulcerative colitis, conditions known collectively as inflammatory bowel disease (IBD). The “never knowing, always wondering” refers to the way people with these conditions often have unpredictable bouts of diarrhea and an urgent need to get to a restroom. And that’s why there are toilets everywhere.

What does this ad get right?

The ad provides useful information about:

• How this treatment works. Crohn’s disease and ulcerative colitis are two forms of IBD that cause inflammation of the intestinal tract. Given as an infusion every two months, vedolizumab works by blocking cells involved in that inflammation. The ad uses visually appealing animations and graphics to get these points across.
• Side effects. The FDA requires every drug ad to describe common and potentially serious side effects. For vedolizumab, possible side effects include infusion reactions, allergic reactions, liver problems, and an increased susceptibility to infection. The ad highlights an infection called PML, noting that it’s “a rare, serious, potentially fatal brain infection.”
• Benefits. The voiceover states that “in clinical trials, Entyvio helped many people achieve long-term relief and remission.”

What else do you need to know?

As with most drug ads, this ad doesn’t provide all the information that’s important to know about this medication, especially if you’re a person with IBD for whom this drug might be helpful.

For starters, the ad never explains that diarrhea and abdominal pain are among the most common symptoms of Crohn’s disease and ulcerative colitis. And while the ad focuses on frequent diarrhea, it never mentions more serious complications, such as

• bleeding, fistulas (abnormal connections between the intestines and other parts of the body), perforation of the bowel, and bowel blockage 
• an increased risk of colorectal cancer
• inflammation in other parts of the body, including joints and eyes.

The ad also omits:

• Explaining how moderate to severe Crohn’s and ulcerative colitis is defined. Generally, it would include people with either condition who have large areas of intestinal inflammation, deep ulcers in the walls of the intestines, or who have had surgery; and those who haven’t responded to other standard treatments.
• Other ways to treat Crohn’s disease or ulcerative colitis. Steroids, azathioprine, infliximab, ustekinumab, risankizumab, and other drugs are also options to treat these disorders. 
• The high cost of this drug (up to $52,000/year). For some, health insurance may cover much of this cost, and a discount program is mentioned at the end of the ad (though eligibility details are not provided). Still, for many people with IBD, the cost of expensive drugs like Entyvio is a major barrier to receiving optimal care.

Also troubling is the way the ad skims over two important points:

• Little information is provided about PML. The ad doesn’t even say what the letters stand for: progressive multifocal leukoencephalopathy. PML is a virus that can infect the brain, often causing death or severe neurologic disease.
• What benefits does the drug deliver? Only one sentence speaks confidently about benefits, and no details are provided. How often people do taking this drug have at least some relief from their symptoms? How often do they experience remission of symptoms? And how long do these improvements last?

The bottom line

The ad ends with the young woman driving home after her doctor’s visit. She’s sitting on a regular seat for the first time. She glances at the rearview mirror and smiles at the toilet that’s been relegated to the back of the car. The message is clear: she’s better now and doesn’t have to worry about having to rush to the toilet since her doctor prescribed vedolizumab.

Of course, it doesn’t always work out this way in real life. Then again, drug ads aren’t intended to show real life. They’re intended to promote a product. That’s a good reason to maintain a healthy dose of skepticism about drug ads, and to rely instead on your doctor and other unbiased sources for your health information, such as the National Institutes of Health websites.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

When you first learned the facts about pregnancy — from a parent, perhaps, or a friend — you probably didn’t learn that up to one in three ends in a miscarriage.

What causes miscarriage? How is it treated? And why is appropriate health care for miscarriage under scrutiny — and in some parts of the US, getting harder to find?

What is miscarriage?

Many people who come to us for care are excited and hopeful about building their families. It’s devastating when a hoped-for pregnancy ends early.

Miscarriage is a catch-all term for a pregnancy loss before 20 weeks, counting from the first day of the last menstrual period. Miscarriage happens in as many as one in three pregnancies, although the risk gradually decreases as pregnancy progresses. By 20 weeks, it occurs in fewer than one in 100 pregnancies.

What causes miscarriage?

Usually, there is no obvious or single cause for miscarriage. Some factors raise risk, such as:

• Pregnancy at older ages. Chromosome abnormalities are a common cause of pregnancy loss. As people age, this risk rises.
• Autoimmune disorders. While many pregnant people with autoimmune disorders like lupus or Sjogren’s syndrome have successful pregnancies, their risk for pregnancy loss is higher.
• Certain illnesses. Diabetes or thyroid disease, if poorly controlled, can raise risk.
• Certain conditions in the uterus. Uterine fibroids, polyps, or malformations may contribute to miscarriage.
• Previous miscarriages. Having a miscarriage slightly increases risk for miscarriage in the next pregnancy. For instance, if a pregnant person’s risk of miscarriage is one in 10, it may increase to 1.5 in 10 after their first miscarriage, and four in 10 after having three miscarriages.
• Certain medicines. A developing pregnancy may be harmed by certain medicines. It’s safest to plan pregnancy and receive pre-pregnancy counseling if you have a chronic illness or condition.

How is miscarriage diagnosed?

Before ultrasounds in early pregnancy became widely available, many miscarriages were diagnosed based on symptoms like bleeding and cramping. Now, people may be diagnosed with a miscarriage or early pregnancy loss on a routine ultrasound before they notice any symptoms.

How is miscarriage treated?

Being able to choose the next step in treatment may help emotionally. When there are no complications and the miscarriage occurs during the first trimester (up to 13 weeks of pregnancy), the options are:

Take no action. Passing blood and pregnancy tissue often occurs at home naturally, without need for medications or a procedure. Within a week, 25% to 50% will pass pregnancy tissue; more than 80% of those who experience bleeding as a sign of miscarriage will pass the pregnancy tissue within two weeks.

What to know: This can be a safe option for some people, but not all. For example, heavy bleeding would not be safe for a person who has anemia (lower than normal red blood cell counts).

Take medication. The most effective option uses two medicines: mifepristone is taken first, followed by misoprostol. Using only misoprostol is a less effective option. The two-step combination is 90% successful in helping the body pass pregnancy tissue; taking misoprostol alone is 70% to 80% successful in doing so.

What to know: Bleeding and cramping typically start a few hours after taking misoprostol. If bleeding does not start, or there is pregnancy tissue still left in the uterus, a surgical procedure may be necessary: this happens in about one in 10 people using both medicines and one in four people who use only misoprostol.

Use a procedure. During dilation and curettage (D&C), the cervix is dilated (widened) so that instruments can be inserted into the uterus to remove the pregnancy tissue. This procedure is nearly 99% successful.

What to know: If someone is having life-threatening bleeding or has signs of infection, this is the safest option. This procedure is typically done in an operating room or surgery center. In some instances, it is offered in a doctor’s office.

If you have a miscarriage during the second trimester of pregnancy (after 13 weeks), discuss the safest and best plan with your doctor. Generally, second trimester miscarriages will require a procedure and cannot be managed at home.

Red flags: When to ask for help during a miscarriage

During the first 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• heavy bleeding combined with dizziness, lightheadedness, or feeling faint
• fever above 100.4° F
• severe abdominal pain not relieved by over-the-counter pain medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Please note: ibuprofen is not recommended during pregnancy, but is safe to take if a miscarriage has been diagnosed.

After 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• any symptoms listed above
• leakage of fluid (possibly your water may have broken)
• severe abdominal or back pain (similar to contractions).

How is care for miscarriages changing?

Unfortunately, political interference has had significant impact on safe, effective miscarriage care:

• Some states have banned a procedure used to treat second trimester miscarriage. Called dilation and evacuation (D&E), this removes pregnancy tissue through the cervix without making any incisions. A D&E can be lifesaving in instances when heavy bleeding or infection is complicating a miscarriage.
• Federal and state lawsuits, or laws banning or seeking to ban mifepristone for abortion care, directly limit access to a safe, effective drug approved for miscarriage care. This could affect miscarriage care nationwide.
• Many laws and lawsuits that interfere with miscarriage care offer an exception to save the life of a pregnant patient. However, miscarriage complications may develop unexpectedly and worsen quickly, making it hard to ensure that people will receive prompt care in life-threatening situations.
• States that ban or restrict abortion are less likely to have doctors trained to perform a full range of miscarriage care procedures. What’s more, clinicians in training, such as resident physicians and medical students, may never learn how to perform a potentially lifesaving procedure.

Ultimately, legislation or court rulings that ban or restrict abortion care will decrease the ability of doctors and nurses to provide the highest quality miscarriage care. We can help by asking our lawmakers not to pass laws that prevent people from being able to get reproductive health care, such as restricting medications and procedures for abortion and miscarriage care.

About the Authors

Sara Neill, MD, MPH, Contributor

Dr. Sara Neill is a physician-researcher in the department of obstetrics & gynecology at Beth Israel Deaconess Medical Center and Harvard Medical School. She completed a fellowship in complex family planning at Brigham and Women's Hospital, and … See Full Bio View all posts by Sara Neill, MD, MPH

Scott Shainker, DO, MS, Contributor

Scott Shainker, D.O, M.S., is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center (BIDMC). He is also a member of the faculty in the Department of Obstetrics, … See Full Bio View all posts by Scott Shainker, DO, MS