Life was getting underway the day I found a suspicious lump. My first book had just been published and was being received well in my field. I was traveling and speaking about a new research project. The phone kept ringing and there was little time to think.
I figured that was the reason why my weight was falling. It was one of those good side benefits of a busy schedule. Why worry about a pea-sized lump? Lots of women have those and they turn out to be nothing. Coincidentally, that was exactly what my gynecologist said it was: nothing but a cyst.
Two more visits to that doctor resulted in him telling me that, at my age and with my family history, there was nothing to worry about and I should get on with life. He refused my request for a mammogram, suggesting that I should relax. I gave relaxation a try until a friend told me, “You look bad. If you don’t go see your GP for another opinion, I’m not going to talk to you.” There were dark lines under my eyes and I was becoming tired and downright skinny. I took her advice. It was cancer.
When I read about young people declining to sign up for health insurance, I remember back to that time. Sure, it’s great to be young. One of the best things is thinking you have a long time before you need to worry about your body giving you major problems. And isn’t life a gamble anyway?
I’m sure many young people reason this way and to some extent they’re right. Having spent a significant part of my career studying how people reason about health, it’s no surprise to me that weighing the odds causes a good many of us to take risks.
Yet, there is no such thing as a “young invincible,” the term currently bandied about to describe adults under the age of 35.
It’s not their fault if the system is unresponsive when they attempt to learn their insurance options. But it is their responsibility, to themselves and their families, to make sure that if something does go wrong — as it often does — their insurance will afford them the care that could save their lives.
Continue reading “Think You’re Young and Invincible? You’re Young, Yes. Invincible? Maybe Not.”
Filed Under: OP-ED
Tagged: Cancer, Health insurance, Health Plans, Kathleen Reardon, The Affordable Care Act, Young Invincibles
Nov 18, 2013
On February 16 of last year, I was in a New Orleans hotel room preparing for a meeting when my wife Becky called and said simply, “I have cancer.”
We knew it was possible, but that didn’t in any way lessen the impact of those three words.
I have cancer.
Everything that was right and comfortable was in that instant washed away by a million questions with no answers. At a time when we needed nothing more than certainty and clarity, there was only confusion and doubt.
Upon landing in Philadelphia hours later, I called to see how she was doing with her newly diagnosed breast cancer. Feeling numb, I managed to make one other call soon after landing. Not to friends. Not to family. Instead, it was to our insurance company.
That’s right: Other than my wife, the one person I most wanted to speak to in the world was a Cigna call center operator.
We hadn’t even had a chance to meet with her oncologist to discuss potential courses of treatment, but we had questions because we had recently changed our plan to carry higher out-of-pocket costs and lower deductibles. We needed answers to those questions so we could go about worrying about more important things.
What procedures are covered? Are the doctors at the cancer center in plan? What is the maximum out of pocket? What other limits should we know about?
A 15-minute conversation later, we were comfortable that insurance wouldn’t be an issue and had a decent understanding of what our share of the costs would be. At a time of absolute fear and confusion, our insurer provided a moment of comfort and clarity.
That is the kind of financial and emotional stress that millions of people face every day in the United States. That is also the kind of financial and emotional security the Affordable Care Act was supposed to provide — especially to those who currently lack health insurance. Continue reading “My Wife Has Cancer. I Need to Know: Will She Have Insurance On January 1st?”
Filed Under: Health Plans, THCB
Tagged: Cancer, Cigna, Health Insurance Exchanges, Life In the Affordable Care Act, The Affordable Care Act, Tony Jewell
Nov 13, 2013
What do Louis Pasteur, Jonas Salk, Sigmund Freud and Barack Obama have in common? They all championed controversial medical revolutions and if not for their bravery in the face of conflict, billions would have died.
Sterilize instruments to kill invisible bugs? Inject disease particles to build immunity? Look into our subconscious to explain everyday behavior? Give basic healthcare to everyone? Ludicrous. That is why we named these advances after these men.
As an oncologist who has seen the fatal cost of our patchy, imbalanced and unfair healthcare system, I have to be at very least hopeful about ObamaCare; AKA the Affordable Care Act (ACA). The list of benefits is so vast that whatever glitches happen along the way, I know that cancer patients will be helped:
-No pre-existing condition exclusion: So the 31-year-old programmer with Stage 1 breast cancer can change jobs without losing insurance.
-Healthcare coverage by parents until their child is 26: So families will not lose their homes paying for Hodgkin’ s disease in a 22-year-old.
-Guaranteed payment by insurers for patients entering experimental trials: So patients with any insurance can be involved in research, and everyone benefits from the latest advances.
-Free healthcare screening: So that my 58-year-old neighbor with a family history of colon cancer gets routine exams and life saving colonoscopies.
-Uniform healthcare insurance standards: So that the 45-year-old man with stomach lymphoma I saw last week, does not have to suffer and die because his employer brought a health policy, which excluded chemotherapy.
Continue reading “The Next Great Cure? A Cancer Doctor Explains Why He Supports the Affordable Care Act”
Filed Under: OP-ED, THCB
Tagged: Cancer, James Salwitz, Oncology, Patients, Physicians, The Affordable Care Act
Oct 4, 2013
A preventive breast cancer vaccine developed by Professor Vincent Tuohy of the Cleveland Clinic will be brought forward to the FDA for permission to begin clinical trials to see if it is safe and effective for use in women.
The vaccine was shown to be completely safe and 100% effective in preventing breast cancer in three animal models, (see study in Nature Medicine), and was also found to slow the growth of tumors that had already formed. The vaccine is especially powerful in inhibiting the growth of triple-negative breast cancer, the most aggressive form of the disease with the lowest survival rate.
Triple-negative breast cancer lacks estrogen, progesterone and Her2 receptors. It occurs in approximately 15% of cases is the kind of breast cancer most common in women who carry a BRCA mutation.
The initial clinical trials, called Phase I studies, will be conducted in two groups of volunteers, women with triple-negative breast cancer who have completed their treatment and are free of disease, and women who will be vaccinated shortly before undergoing bilateral prophylactic mastectomy (typically these are women like Angelina Jolie with BRCA mutations who elect to remove their breasts to lower their risk for cancer.)
The first group of women will be studied to determine the dose and effectiveness of the vaccine; the second will be studied to make sure the vaccine does not trigger an untoward immune response in breast tissue.
The vaccine targets an unique protein normally made only by women who are breastfeeding, alpha lactalbumin (ALA). In the 12 years Tuohy spent developing and researching his vaccine, he discovered that the majority of breast tumors express, or make, ALA. Priming the immune system with a vaccine so that it attacks any cell that makes ALA is the method by which Tuohy’s vaccine works.
Because the vaccine targets ALA, a protein necessary for successful lactation in healthy women, the vaccine would not be appropriate for use in women who are still in their childbearing years.
However, the majority of women diagnosed with breast cancer in the United States and other western countries are post-menopausal: at least 60% of the cases in the United States occur in women over 55; thus, Tuohy’s vaccine holds great potential as a preventive vaccine for the majority of women.
Continue reading “Cleveland Clinic Trial of Breast Cancer Vaccine Moves Forward”
Filed Under: OP-ED, THCB
Tagged: Breast cancer, Breast Cancer Vaccine, Cancer, Cleveland Clinic, Clinical Trials, Kathleen Ruddy, prevention, Vincent Tuohy, Women's Health
Sep 21, 2013
It was spring. My medical school class, two years along in our five-and-a-half year endeavor, had earned the “medicinae kandidat” degree. We were now worthy of leaving the basic sciences and research center on the outskirts of town and starting our preparatory clinical, “propedeutic” semester at the University Hospital. In Sweden, at that time, we used a lot of Latin words and phrases. Crohn’s disease was Morbus Crohn, chart notes listed physical exam findings by Latin names for the bodily organs: Cor for the heart, Pulm(ones) for the lungs, Hepar for the liver, etc.
Uppsala Academic Hospital was an imposing campus, with several tall, white towers, housing the most modern wards, laboratories and operating theaters. We were relegated to a pink stucco building that housed the old tuberculosis clinic.
The physical exam course was taught by a couple of older pulmonologists. At first they struck many of us as relics from a bygone era, but as the course went on, our respect grew. These unassuming physicians could percuss a patient’s chest wall and describe in detail what the x-ray would look like, they made us feel the tip of the spleen by turning the patient on his right side, they measured jugular venous pulsations and pedal pulses.
Sometimes we had real patients with remarkably abnormal findings to examine, but we often were charged with examining each other for assessment of normal physical exam findings.
My partner for the Lymphatic System module was Sven Björk, a slow-talking kid from the very north of Sweden. He had jet black, completely straight hair and a broad face with eyes set wide apart. He was part Same, the native, reindeer-herding nomadic population from north of the Arctic Circle.
Continue reading “Morbus Propedeuticus”
Filed Under: Physicians
Tagged: Cancer, Country Doctor, International, Lymphoma, Medical Student's Disease, Morbus Propedeuticus
Sep 3, 2013
The general practice of oncology seems to come in waves of disease. One week every breast cancer patient is in trouble, another sees multiple new cases of lymphoma or leukemia, the next it as if someone is giving away lung cancer (or perhaps cigarettes) and then three patients with pancreatic cancer end up in the ICU. This week a portion of the 240,000 yearly USA cases of prostate cancer walked in our door. The rush of cases served as a reminder that when it comes to this illness, we have a long way to go.
First, Allen. He is 73 years old and has prostate cancer in one out of twelve biopsies. The cancer has a Gleason’s Score of 6 (a measure of aggressiveness of the cancer tissue: more then 7 is particularly bad), which means it is not fast growing. We recommended that given the small amount of slow growing cancer, Allen should be watched without treatment (“Active Surveillance”). What Allen found so difficult about this recommendation is that his son was diagnosed with prostate cancer just one month ago and his son, who is 49, has a Gleason’s 8 Prostate Cancer on both sides of the prostate, and is scheduled for robotic surgery. More than having cancer, Allen is hurt by the feeling it should have been him.
Then there was Robert and Mike. Robert was in the office at 10:00am for evaluation of his newly diagnosed prostate cancer, PSA blood test 32 (high), Gleason’s 7, with evidence of invasion through the capsule of the prostate gland. Fortunately, because prostate cancer likes to spread to bone, his bone scan is normal. Despite Robert’s relatively young age (66), the surgeon recommends external beam radiation therapy (RT) instead of operating. What is bizarre and makes my head spin, was that at1:00pm, in the same exam room, in the same chair, I saw Mike. He has recurrence of prostate cancer, previously treated with surgery. Now Mike needs RT. Although Robert and Mike do not know that the other has cancer, they have worked together in the same small company for 28 years, and consider each other friends.
Continue reading “Prostate Cancer: Not a Good Week”
Filed Under: OP-ED
Tagged: Cancer, Cancer Screening, James Salwitz, Oncology, prevention, Prostate Cancer
Aug 30, 2013
The wellness emphasis in the Affordable Care Act is built around the Centers for Disease Control and Prevention’s (CDC) 2009 call to action about chronic disease: The Power to Prevent, the Call to Control. On the summary page we learn some shocking statistics:
“Chronic diseases cause 7 in 10 deaths each year in the United States.”
“About 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness.”
“More than 75% of health care costs are due to chronic conditions.”
Shocking, that is, in how misleading or even false they are. Take the statement that “chronic diseases cause 7 in 10 deaths,” for example. We have to die of something. Would it be better to die of accidents? Suicides and homicides? Mercury poisoning? Infectious diseases? As compared to the alternatives, it is much easier to make the argument that the first statistic is a good thing rather than a bad thing.
The second statistic is a head-scratcher. Only 223 million Americans were old enough to drink in 2009, meaning that 60% of adults, not “nearly 1 in 2 adults,” live with at least one chronic illness — if their language is to be taken literally. Our suspicion is that their “133-million Americans” figure includes children, and the CDC meant to say “133-millon Americans, including nearly 1 in 2 adults, live with at least one chronic illness.” Sloppy wording is not uncommon at the CDC, as elsewhere they say almost 1 in 5 youth has a BMI > the 95th percentile, which of course is mathematically impossible.
More importantly, the second statistic begs the question, how are they defining “chronic disease” so broadly that half of us have at least one? Are they counting back pain? Tooth decay? Dandruff? Ring around the collar? “The facts,” as the CDC calls them, are only slightly less fatuous. For instance, the CDC counts “stroke” as a chronic disease. While likely preceded by chronic disease (such as hypertension or diabetes) and/or followed by a chronic ailment in its aftermath (such as hemiplegia or cardiac arrhythmias), a stroke itself is not a chronic disease no matter what the CDC says. Indeed it is hard to imagine a more acute medical event.
They also count obesity, which was only designated as a chronic disease by the American Medical Association in June–and even then many people don’t accept that definition. Cancer also receives this designation, even though most diagnosed cancers are anything but chronic – most diagnosed cancers either go into remission or cause death. “Chronic disease” implies a need for and response to ongoing therapy and vigilance. If cancer were a chronic disease, instead of sponsoring “races for the cure,” cancer advocacy groups would sponsor “races for the control and management.” And you never hear anybody say, “I have lung cancer but my doctor says we’re staying on top of it.”
Continue reading “The Biggest Urban Legend in Health Economics–and How It Drives Up Our Spending”
Filed Under: THCB
Tagged: Al Lewis, Body Mass Index (BMI), Cancer, CDC, chronic disease, Obesity, overdiagnosis, Overtreatment, prevention, Vik Khanna, Wellness
Aug 24, 2013
Before undergoing many health care interventions, patients are asked to give their informed consent. In most cases, it represents a mere formality. The patient has come to the healthcare facility for the express purpose of undergoing the test or treatment, and after a quick explanation, the patient signs the consent form. But not always – sometimes patients elect not to go through with it.
I know a woman in her late 70s, a highly accomplished health professional with a long and remarkably distinguished record of career achievement, who was recently diagnosed with cancer. Her physician advised a complete diagnostic workup to determine how far the disease has spread, to be followed by courses of radiation and chemotherapy. A vast and sophisticated medical armamentarium, unprecedented in the history of medicine, stands at the ready to take the full measure of her disease and then beat it back.
Yet after her oncologist carefully explained the benefits, risks, and alternatives to the recommended course, she declined to proceed further. Instead of launching into an arduous medical regimen, she has chosen to focus the remainder of her time and attention elsewhere, on matters outside of medicine. Why?
On hearing such a story, some of my medical colleagues question the patient’s soundness of mind. Could she be depressed? Might she be in the early stages of dementia? Could she have simply failed to grasp the full gravity of her situation? To them, the failure to take advantage of the wonders of modern medicine smacks of irrationality. The solution? Her physicians need to sit her down again and explain the situation more clearly. Should this fail to elicit her consent, perhaps a psychiatry consult would be in order.
Yet to those who know her, these explanations are unsatisfactory. We cannot attribute her decision to a lack of intelligence or sophistication about healthcare. She has spent her entire career in the field, and helped to care for countless patients with life-threatening conditions, many of whom eventually died. She knows what the care of such patients looks and feels like from firsthand experience. She understands the risks of declining further treatment at least as well as many of the health professionals caring for her.
Continue reading “Informed Refusal”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: Cancer, End of life decisions, Patients, Richard Gunderman
Aug 18, 2013
The late Dr. C. Everett Koop was the most revered Surgeon General in history, perhaps even the most revered Cabinet member. His calling card—indeed, his claim to fame – was his integrity. A Reagan appointee, he acted as though he reported to no one other than the American people and his own conscience. His penchant for candor and scientific independence fueled the federal government’s groundbreaking steps to raise public awareness about HIV/AIDS at a time when the tendency was to demonize and diminish. He resisted incessant political pressure and refused to take positions or produce data that he knew to be false.
This drew strong support from both sides of the aisle, and even his detractors never questioned his honesty. (Exhibit A: The two authors of this posting, whose political views have little else in common other than respect for strong, independent-minded politicians.)
Dr. Koop’s legacy stands in sharp contrast to the eponymous award dispensed by The Health Project, whose committee members have turned their back on their founder. The last thing Dr. Koop would have expected is to see is *his* award bestowed upon people who know that they don’t deserve it. The 2012 award was given to three recipients for work done in Nebraska: a vendor that claims wellness programs don’t even have to exist to save money, an outfit that can’t even spell the name of its own founder, and a state employee benefits plan that is under investigation for sky-high administrative costs.
Among the extravagant statements that formed the basis for the award (like claiming more than $20,000 in savings for every person who reduced their risk factors for a year, even though per-person spending is only $6,000), they claimed to have made 514 “life-saving catches” on employees with otherwise undetected cancer. This data was obviously wrong to begin with — that cancer rate would have been at least 40 times greater than Love Canal’s. Nonetheless, it sure sounded good, and the Governor of Nebraska himself was all-in too, so an award was issued.
Continue reading “The Strange Case of the C. Everett Koop National Health Award”
Filed Under: THCB, The Business of Health Care
Tagged: Al Lewis, C. Everett Koop, Cancer, Nebraska, public health, The Health Project, Vik Khanna, Wellness
Aug 8, 2013
It’s fitting that this year’s ACOG meeting was held in New Orleans, because navigating the 2013 ASCCP Pap Smear Management Guidelines presented there feels like trying to make my way through the Mississippi bayou. The guidelines include 18 different algorithms encompassing almost any combination of pap and HPV abnormality we docs are likely to encounter among our patients. But all tributaries lead to the same place, where we achieve optimal reduction in cervical cancer with minimal harm.
Cervical cancer prevention is a process with benefits and harms. Risk cannot be reduced to zero with currently available strategies, and attempts to achieve zero risk may result in unbalanced harms, including over treatment. …optimal prevention strategies should identify those HPV-related abnormalities likely to progress to invasive cancers while avoiding destructive treatment of abnormalities not destined to become cancerous. Adopted management strategies provide what participants considered an acceptable level of risk of failing to detect high-grade neoplasia or cancer in a given clinical situation.
I’m not even going to try to spell out everything in the guidelines, which come from the American Society of Colposcopy and Cervical Pathology (ASCCP), except to say that they represent further movement away from aggressive screening and treatment of pap smear abnormalities, especially in younger women, in whom treatment carries small but real childbearing risks. The guidelines are increasingly reliant upon HPV testing to determine who and how often to screen, and when to treat. They also acknowledge the role of testing for HPV 16 and 18 as a way to be sure that those women with adenocarcinoma of the cervix (which is less likely to show up as cancer on a pap smear) are identified and treated.
From the guidelines-
Continue reading “The New HPV Guidelines. Balancing Benefits and Harms of Cervical Cancer Screening”
Filed Under: Uncategorized
Tagged: Apps, Cancer, Cervical Cancer Screening, HPV, Margaret Polaneczky, Pap Smears, prevention, USPSTF
Jul 9, 2013