Dear Doctor: I am a 64-year-old male in good health, although I have a bit of a gut in the middle. My issue is that I have developed an umbilical hernia that looks like a large "outie." It is not very attractive, but it is not causing any pain or discomfort. What course of action should I take?

Dear Reader: Umbilical hernias, or so-called "belly-button hernias," are quite common. They occur because of tissue weakness at the umbilical ring. The weakness allows the contents within the abdomen to bulge into the opening, thus making an "innie" appear like an "outie." In children with umbilical hernias, the hernia develops because of incomplete closure of the belly-button (umbilicus) at birth. In adults, umbilical hernias develop because of increased pressure within the abdomen that stretches and weakens the tissue (fascia) at the umbilicus. Increased pressure in the abdomen can be caused by obesity, pregnancy or fluid in the belly from diseases such cirrhosis or ovarian cancer.

Umbilical hernias are three times more common in women than in men. The material that typically bulges within a hernia is fat from the abdomen and the lining of the abdominal cavity. In the majority of people, the herniation doesn't hurt. However, when the lining of the abdominal cavity (the omentum) becomes stuck within a hernia, the area can become painful. Even worse is when the small intestine becomes stuck. Called an incarcerated hernia, this compression leads to a loss of blood flow to the intestine, which can cause severe pain, altered bowel movements and possible death of the bowel tissue. The omentum and the intestine are more likely to become entrapped in men. Women more commonly have umbilical hernias that are reducible, meaning the material that pushes into the hernia can easily be moved back into the abdomen.

A small umbilical hernia without symptoms doesn't require treatment. That changes if a hernia causes pain or is not reducible. For a small, symptomatic hernia, a surgeon cuts into the skin and locates the hernia sac. He or she then removes the sac or pushes it back into the abdomen; sutures the surrounding fascial layers together; and thus closes the area of weakness. With a larger hernia, a surgeon will have difficulty bringing together the surrounding fascial layers. This is when he or she will place a mesh over the defect and attach the mesh to the surrounding fascial layers. Unless the hernia is very large (more than 9 centimeters in size), a surgically repaired hernia is unlikely to recur or cause pain.

Because of the lack of symptoms from your hernia, you're unlikely to need surgical treatment. But you should be on the alert for pain in the umbilical area and for difficulty pushing the hernia back in to the abdomen. Either problem is a sign that surgery might be needed.

Also, you might be able to decrease pressure on the abdomen by decreasing your "gut in the middle." Improving your diet by cutting back on sugar, exercising and losing weight will put less pressure upon the hernia and may decrease the likelihood of ever needing hernia surgery.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: My dad and brothers are hunters, so there's always deer meat in the freezer and it's often on the menu. But I'm hearing that it's now linked to a brain disease. Should we be worried?

Dear Reader: You're referring to chronic wasting disease, also known as CWD, which has now been found in deer herds in at least 23 states. It has also been identified in moose, elk and reindeer, and is a becoming a problem in Canada, Norway and South Korea as well.

Chronic wasting disease is a progressive disease that affects the functioning of the brain and spinal cord of the infected animals, and invariably leads to their death. Although it is highly contagious among animals -- the disease continues to spread in wild deer herds and fenced-in hunting ranches -- there are no known cases of transmission to humans at this time.

CWD is part of a family of disorders known as prion disease. If that sounds familiar, it's because prions play a leading role in mad cow disease. The disease created an uproar when it was identified in Great Britain, Europe and the United States in the late 1980s through the early 2000s. Mad cow caused several hundred deaths in humans, mostly in Great Britain, and resulted in 4.5 million cows being destroyed.

Although prions are normal proteins found in the brains and nervous systems of most animals, including mammals, reptiles and birds, the prions involved in the disease process behave abnormally. They start a chain reaction among the normal proteins in the brain, causing them to fold and bend and become deformed. This prevents the proteins from fulfilling their specific biological purposes, and ultimately results in the characteristic spongy appearance in the brain tissues of the infected animal. In CWD, prions cause numerous small holes to develop in the brains of infected deer, which affect the deer's behavior and lead to death.

Symptoms in infected deer include tremors, loss of coordination, weight loss and wasting, a lack of awareness of the surroundings, an uncharacteristic loss of fear of humans, and increased thirst, urination and salivation. The incubation period of CWD is quite long, averaging from 18 to 24 months. That means an animal can be infected with the disease but not show any ill effects. CWD is transmitted among herds of deer through normal contact, like touching noses, licking, mating and giving birth. In addition, soil contaminated by the urine, feces or carcass of an affected animal remains a vector of infection for more than a decade.

CWD was first identified in the late 1960s, but as we mentioned earlier, there are no known instances of transmission to humans. However, because mad cow made the leap to humans, scientists are now investigating whether the same thing can happen with CWD. Wildlife officials in Colorado and other heavily affected states are urging hunters to bring their deer in for testing before consumption. This involves an analysis of tissues from the brain and lymph nodes. The agency that issued your hunting permit will have complete information.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: A friend of mine was recently diagnosed with breast cancer and is terrified of the chemotherapy her doctor is recommending. I read that some women can skip it. Is this true?

Dear Reader: Your friend's fear of chemotherapy is understandable. Its harsh side effects and its risk of toxicity to the body's organs are well-known. However, survival rates significantly improve with chemotherapy. This too is well-known -- and has been shown even in women with breast cancer that hasn't spread to the lymph nodes.

A recent study in The New England Journal of Medicine, however, has called into question the need for chemotherapy in some women who have breast cancer without lymph node metastasis. The trial looked at 9,719 women, ages 18 to 75, with cancer that was hormone receptor-positive and HER2-negative. Such cancer is often treated with hormone therapy, although chemotherapy can be used as well. In this trial, the authors gauged the need for chemotherapy based on a genetic tool called the 21-gene breast cancer assay, which evaluates the risk of recurrence based on 16 cancer-related genes and five other genes. Women who have higher scores in the screening have been shown to have a greater risk of recurrence of breast cancer compared to those with lower scores.

In this study, women with a 21-gene score of 26 or greater received chemotherapy and endocrine therapy (medications that block the estrogen receptor in breast cancer). Those with scores of 11 to 25 received either chemotherapy with endocrine therapy (chemoendocrine therapy) or endocrine therapy alone. Those with a score of 10 or less received only endocrine therapy. The majority of women in the trial (6,711) had scores between 11 and 25. All patients were followed for eight years.

In the group with scores of 11 to 25, no statistically relevant difference was found between those who received chemoendocrine therapy and those who received endocrine therapy alone. Although there was a small non-significant increase in the rate of recurrence at a local or distant site with endocrine therapy, there was no difference in survival rates between those who received chemotherapy and those who didn't. Extrapolating the data to nine years, the rate of invasive-free survival with chemoendocrine therapy would have been 84.7 percent, while it would have been 83.1 with endocrine therapy alone. The small difference suggests that chemotherapy might not be necessary in all patients with a midrange score.

For some, however, it might be. In women younger than 50, those with a 21-gene assay score of 16 to 25 showed a decrease in the rate of recurrence with chemotherapy. Still, no difference was seen in the survival rates.

I can't say what your friend should or shouldn't do. Perhaps -- unlike in this study -- her breast cancer involves lymph nodes and is hormone receptor-negative or HER-2 positive. Further, if she's under 50 and has a gene score of 16 or greater, she would almost certainly benefit from chemotherapy.

But, overall, the study does show that for many women with localized breast cancer, and a 21-gene assay score of 25 or less, chemotherapy may not be necessary.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)