Elizabeth Edwards, Breast Cancer, and Mammograms - Her Death a Failure of Healthcare System.

Elizabeth Edwards died recently of breast cancer at 61, leaving behind three children, Cate (28), Emma Claire (12), and Jack (10).  Described by her eldest daughter as intelligent, humorous, and witty, I'm fairly certain that she would not have wanted to leave her children at such a young age. Yet, in November 2004, shortly after the presidential election, she announced to the public that she had discovered a breast lump, which ultimately was diagnosed as cancer.  She admitted shortly after her diagnosis that at age 55 that she had not been screened for breast cancer with a mammogram for about four years.

Which is why the recent report from the San Antonio Breast Cancer Symposium, done annually in December, is particularly worrisome.  The study period between 2006 to 2009 found these screening rates to be lower rates than the past.  Only 50 percent of women eligible to be screened for breast cancer actually did so.  That number improved slightly to 60 percent with women receiving two mammograms over a four year period.

In other words, 40 percent of women, who should get mammograms, aren't getting them.  

Just like Elizabeth Edwards.

Is it personal choice?  A cost issue?  Or lack of time?  Lack of understanding?  While experts debate, I'll tell you.

It's a lack of time and lack of understanding.  Everyone is incredibly busy.  Given a choice, patients will do the right thing if they are nudged to do so.  In fact, they want doctors to help guide them to the correct choice.  Elizabeth Edwards certainly as a mother and professional woman had the financial resources and intelligence to know the importance of annual mammograms starting at age 40, yet didn't do so.  Perhaps she didn't think she was at risk.  Maybe she was focused on her children and husband and didn't care for herself as much as she should have, a common trait for many mothers.

The question is was she reminded of her options?  If she was a patient in my practice, she would have benefited from a team effort that constantly worked to keep her healthy.  At every office visit, whether with a primary care doctor or a specialist, every patient at every check-in received a personalized checklist that is age appropriate.  Ms. Edwards would have seen on her checklist that she was overdue for her mammogram.

To make it incredibly easy to get it done, all of the medical offices that her doctors work at have a radiology department with mammogram machines.  To make it even easier, patients can walk-in to have them done.  No appointments needed.   No paper work required.  She simply would have finished up with her doctor, checked in with radiology, and had her mammogram.

If by chance she was busy and otherwise healthy and hadn't seen a doctor face to face, but was overdue then she would have been notified by mail at least three times to remind her of that fact.  A team of healthcare providers use the electronic medical record to find which women are overdue, contact them, and then check again to see if the mammogram was done.  If after a few attempts if there still was no response, her primary care doctor would get a message to call her, just to make sure she fully understood the choice she was making.  If she still declined, while that would not be the medically advisable, her decision would be respected.  After all, she is an adult and would have been fully informed about the pros and cons of her decisions.

It's likely, however, that instead of a four year absence, she would have opted for a mammogram.   It would have shown an abnormality months before she actually felt a lump.  Chance of recurrence is much less when breast cancer is caught at a non-palpable stage.

Despite all of the advances in oncology and chemotherapy treatments, the biggest decline in breast cancer deaths over the past 25 years was due to mammogram screening.  Though the new healthcare reform bill which make preventative services like screening for cancer free, that isn't enough.  If people are too busy to remember, much like doing the right thing for retirement planning, they won't do what is in their best interest, even if it is what they would have done if they only had time.

In other words, it isn't about the individual as much as enabling the individual to do the best for herself by designing the system to get the best outcome.  It is true in retirement planning and automotive and road design as it is in healthcare.

I don't believe that if she had such a healthcare system in place to help her stay healthy and well that her life would have ended this way.  While the system I describe exists today in California, where I work, and our breast cancer screening rates are far far better than the study quoted at the San Antonio Breast Symposium, any death that was too soon and preventable in my mind is a failure.  A failure not of the individual patient, but of the healthcare system.

Perhaps that is why she was a health care activist.

Although I've never met her, I am certain that given a choice had she had the healthcare system around her which optimized her chances for the right decision, she would have never wanted to leave her children at such a young age.  The absence of such a system is the true tragedy.

My thoughts are with her family, friends, and most especially her children, Cate, Emma Claire, and Jack.

The Best Health Insurance - Can Save Your Life

The Sacramento Bee recently ran the following opinion piece below.  A couple of additional comments not published follow.  Enjoy. 

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It’s that time of year when most of us pick a health insurance plan based simply on cost. It’s a belief that is often perpetuated by friends, family, and advice dispensed by many articles in magazines and newspapers. As a practicing primary care doctor, I can tell you that the advice is frankly wrong.

Health insurance isn’t a commodity like auto insurance. It’s not just about the price. They aren’t all equally good at keeping you healthy and well. The recent annual report by the National Committee of Quality Assurance, which has been evaluating health plans for twenty years, continues to report tangible differences among health insurance plans across the country as well as in California.

In a ranking of 227 HMO plans nationwide in important areas like immunization rates for children, appropriate use of antibiotics, blood pressure and cholesterol control, cancer screening in adults for breast cancer, cervical cancer, and colon cancer, only two of nine California HMO health insurance plans ranked in the top 15 percent. The remaining seven were in the bottom half. If all health plans across the country performed at the level of the top 10 percent, 186,000 Americans would be alive today. They would have consistently and routinely received the preventive care and medical interventions that have proven to save lives.

Naturally, it is hard to believe that your choice of a health insurance plan might actually save your life. You often pick your insurance based not only on price, but also if your doctor is in the plan. As a patient, high quality care means your doctor sees you quickly when you are ill, he is always willing to listen and explain, and the fact that he actually knows you as an individual. As a result, he should know what to do to keep you healthy, even as research points to the contrary.

A recent study by the Journal of General Internal Medicine found that only 20 percent of doctors correctly screened patients for colon cancer, the second leading cause of cancer deaths. The doctors likely to do the right thing were younger, board-certified, and used electronic medical records. Those most likely to incorrectly screen or not screen at all were older, much like the fictional television doctor, Marcus Welby. He’s a doctor we would all feel comfortable with and we would trust to keep us well.

Who did better, a health plan or a doctor? The HMO health insurance plans in the top 10 percent of performance screened 72 percent of their enrollees appropriately for colon cancer, three and half times more than the doctors. The bottom 10 percent screened 47 percent of patients. The news for enrollees in the more popular PPO plans is more worrisome. Screening rates of these plans were only 54 and 39 percent respectively for the top and bottom 10 percent of plans.

It’s not obvious the reasons for this difference in performance among health plans or the difference between doctors and health plans. Do better health plans have systematic ways of keeping patients healthy or reminding doctors at the point of care? Is it that doctors who are better naturally gravitate to health plans that are focused on prevention? After all, the work of screening and providing the preventive interventions are done by doctors not by insurance companies.

As a practicing primary care doctor, I constantly balance the art of medicine, the bedside manner, and the science, the evidence based research. Before I joined with a high quality health insurance plan, I thought I was pretty good. The initial data showed otherwise. Over the past few years, I’m far better at keeping my patients healthy. With this insight I now know that given a choice, I would always start with health insurance quality first and then the doctors selection second. It doesn’t sound right. It doesn’t feel right. The science part of my medical degree says it is right.

The striking difference between health plan performance means that a choice most of us view as a simple formality or even an annoyance, picking a health insurance plan, is really a choice between getting the best care or not. A true choice between life and death. Intellectually this doesn’t make sense. Doctors take care of us. They are accountable to keeping us well, yet the data and research seems pretty compelling.

This year 186,000 Americans won’t have the opportunity to make the right choice because the health plan they had wasn’t high quality.

Will you make the same mistake this year?

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The two California HMO plans that were in the top 15 percent in the nation were Kaiser Permanente Northern California and Kaiser Permanente Southern California.  Each takes care of more patients than the entire top 10 HMOs combined.

New Pap Smear Guidelines - Rationing Healthcare or the Right Care?

The American Congress of Obstetricians and Gynecologists (ACOG) recently reiterated their position that Pap smear should be performed on healthy women starting at age 21. This is different from the past which recommended screening for cervical cancer at either three years after the time a woman became sexually active or age 21, whichever occurred first.

How will the public respond to this change?

Over the past year there have been plenty of announcements from the medical profession regarding to the appropriateness of PSA screening for prostate cancer and the timing of mammogram screening for breast cancer. Understandably some people may view these changes in recommendations as the rationing of American healthcare.

They should instead, however, welcome these advancements. Doctors becoming even better at understanding which screening tests work and which ones don't.

Doctors have discovered that for cervical cancer, which is detected by Pap smears, a significant risk factor in infection from the human papilloma virus (HPV). HPV is the most common sexually transmitted disease and aside from causing cervical cancer are also the cause of genital warts. Women under age 21, who are healthy and do not have a compromised immune system from HIV or organ transplant, rarely develop cervical cancer from HPV infection.

Unlike the past when women needed annual pap smears, advances in screening with new liquid-based Pap smears as well as screening for HPV allows women to be checked for cervical cancer every other year. Women age 30 and older who have had three normal pap smears in a row can have Pap smears every two to three years with a Pap smear or every three years with a Pap test and HPV DNA screening.

If all doctors recommended these interventions, this would reduce the number of Pap smears needed by 50 percent. The newest cervical cancer screening method would be far better as it identified which women were at risk with better precision and information than the past. By doing fewer unnecessary Pap smears, doctors are now free to address other problems as well as begin to take on the millions of Americans who will have health insurance due to reform.

The question is will they do it? Will women accept the new changes in screening intervals?

Research shows it takes about 17 years before results of studies and guidelines become commonly practiced in the community. One study showed primary care doctors were not particularly good at screening for colon cancer though new guidelines have been around for a decade.

It's easy to blame doctors for being slow to change. It's easy to blame patients for being slow to change. Many of my patients still demand an annual pap smear even though HPV DNA testing is something my colleagues and I have practiced for years.

The fact is that change is hard unless of course you are new to something. As my five year old daughter proudly told me recently there are exactly EIGHT planets not nine in the solar system.

For the next generation of women, they will not need Pap smears until age 21. They can be safely screened every other year. There is a chance that none of them will never develop cervical cancer as since 2006, HPV vaccines exist for individuals age 9 to 26 that immunize them from the subtypes of HPV that cause cancer.

These women won't get upset. They won't get worried.

They know this is the right care. This is not rationed care.

That is, of course, until the next revision in the guidelines and recommendations.

Overtreated: More medical care isn't always better. Doctors must lead change.

The Associated Press recent article "Overtreated: More medical care isn't always better" reiterated a commonly known fact which is not understood by the public. This problem of doing more and yet getting little in return is a common issue which plagues the US healthcare system and was illustrated quite convincingly by Shannon Brownlee's book. Americans get more procedures, interventions, imaging, and tests but aren't any healthier.

In fact they are often worse off. Too many unnecessary back surgeries. Too many antibiotics for viral infections, which aren't at all impacted by these anti-bacterial therapies. Too many heart stents which typically are best used when someone is actually having a heart attack. Research shows that those that are treated with medications do just as well. As all patients with cardiac stents know, they also need to be on the same medications as well.

Eliminating unnecessary treatments is a good thing, particularly when it is based on science.

Already over the past year, cancer screening guidelines have been updated based on reviews of the latest medical evidence. Prostate cancer screening with blood test PSA does not appear to be helpful in determining which men have the life threatening aggressive form requiring treatment and which men have the indolent version which will never impact their health. Some medical experts have suggested that breast cancer screening with mammograms should be moved from age 40 to age 50 based on the review of studies.

You would think the public would be happier that they would be poked and prodded less as scientific evidence shows that it is safe to do so. We should want the healthcare system to be in the mindset of continual learning and not mired in old traditions just because that is the way it was always done.

Yet despite this reality, some people view this as rationing of medical care or the beginning of socialized medicine.

It's not. It's the time of rational medicine. Doctors need to lead the change and get away from the hype and more to the science. That is what patients really want. What is particularly disappointing is that overtreatment is well known and already profiled in various articles two years ago. Change is occurring very slowly. It is unclear why. Despite being bombarded with pharmaceutical advertisements, body scans, and easy access to medical information, patients still trust doctors the most for advice.

If we as doctors fail to lead, then patients will be left to figure it out themselves.

And they are already fearful.

Choosing a Good Physician

As a practicing family doctor, it's easy for me to figure out how to choose a great doctor. Let me tell you the secrets in finding the best one for you and what I tell my family and friends.

Look for the following:

Board certification
Report card on quality
Licensing / public reporting

As a doctor, I know many doctors who have great bedside manner but aren't particularly reliable in getting the right medical care you deserve and these traits separate the so-so doctors from the truly excellent ones.

If you've found one that meets all of the criteria and you know is in in your insurance plan, has convenient office hours and easy access, then I'll give some tips on what to look for to determine if she has excellent bedside manner.

Importance of Board Certification
Your physician should be board certified in his field of expertise. Think of it as the difference between hiring a certified public accountant (CPA) and someone who just files taxes for you. While you might get the same result, if difficult issues come up, you may not get the best advice. Given how much we are all paying for medical care, why would you opt for someone who wasn’t board certified?

To carry this distinction, your doctor must have graduated from an accredited residency program as well as passed the passed the governing board’s certification exam. The examination may be a one-day or two-day written test. Depending on the medical specialty, test takers may also need to take an oral examination.

To maintain their board certification, physicians are required to devote a certain number of hours per year to additional medical education. Doctors often fulfill this requirement by attending conferences and seminars. In addition, doctors must re-certify with a repeat examination every few years to continue their status. Given all of these requirements, a board-certified doctor will often provide the most up-to-date medical care. Ensure that your doctor is board certified. As a recent article noted, doctors most likely to provide the wrong medical care for colon cancer screening were doctors who were NOT board certified.

Your physician may display his board certificate in the office. Some certificates may not have an expiration date because in the past, physicians only needed to take the exam once. It was good for life. This is no longer true. Current graduates can expect to retake the exam every seven to ten years.

Learn more and research your doctor at the American Board of Medical Specialties.


Report Card on Quality.
Find out if your doctor is practicing the latest most up to date medical care by checking out his report card on quality. Is he doing the right things to keep you healthy?

For example, unfortunately in the United States patients who have suffered a heart attack get drastically different care and many don’t get the life saving medication they need to prevent a future event. Less than 50 percent of heart attack patients in Mississippi receive this medication known as a beta blocker. Yet in Massachusetts, nearly every heart attack patient is taking it. This failure to prescribe the medication simply was whether the doctor consistently followed the guidelines established by the American Heart Association. It wasn’t whether the patient could afford the medication since all the patients received the same insurance, Medicare.

A review of 20,000 patients from 12 metropolitan areas showed that 24 percent of breast cancer patients, 27 percent of pre-natal patients, 31 percent of low back pain patients, 32 percent of coronary heart disease patients, and 35 percent of high blood pressure patients did NOT receive the recommended care developed by expert medical committees.

If your doctor isn’t doing the right things that experts recommend, then what else is he doing wrong?

See if your doctor has applied for the NCQA quality recognition designation in any of the following programs - Physician Practice Connections, Heart/Stroke, Diabetes, or Back Pain. This designation is like the Good Housekeeping Seal of Approval. To have this distinction, doctors must show the National Committee of Quality Assurance (NCQA) that they are doing the right things.

You can only use these aspect on primary care doctors (except for the physician practice connections which can be any doctor), like family doctors or internists, as other doctors don't typically participate in these medical problems or illnesses.


Licensing / public reporting
Although your physician does not need to be board certified to practice medicine, he does need to be licensed. Find your own state medical board by going to the Federation of State Medical Boards or simply Google your state (like Connecticut) and medical board.

Each state provides different public information about its doctors. This typically includes the name of the physician, his license number, when the license was issued, and when it expires. Other states provide additional information like history of malpractice suits, felony convictions, or disciplinary action by the medical board. Some states split up the licensing and disciplinary functions into two different departments or websites. While at the state website, look for a link either for physician profile or credential search.

California State Medical Board
New York State Medical Board


The first three items, board-certification, report card on quality, and licensing / public reporting I know is unlikely things you would have come up with.


Bedside Manner
So now that you've found doctors that fulfill these basic requirements, what really is important for all of us is our doctors' bedside manner. If you have friends who are medical assistants, nurses, or others in healthcare, ask for recommendations. Often they see us when we are the most stressed. If they like working with us, then it is likely that they will recommend us.

Not sure you got the best? Here is how you know.

Does she...
Sit down?
Listen?
Know your medical history?
Involve you in the decision making process or get your perspective?
Ask you – do you have any other questions?

Finally, most importantly, does she always wash her hands?

Follow this advice and feel extremely confident that you have a great doctor!

Breast Cancer Screening with Mammograms at age 40? 50? Who is the USPSTF?

When the U.S. Preventive Services Task Force (USPSTF) updated their recommendations and were against routine mammography for women aged 40 to 49, it certainly got a lot of attention. These guidelines are far different than those advocated by the American Cancer Society (ACS) which recommends screening starting at age 40 with annual mammograms.

• Who is the USPSTF?
• What does their recommendations mean for women?
• Why is there conflicting recommendations?

Who is the USPSTF?

The U.S. Preventive Services Task Force (USPSTF) is an independent committee of primary care and preventive physicians that periodically reviews the latest medical research and recommends tests and screening methods that have scientifically been shown to make a difference. As a result, its recommendations are the most conservative of any national organization.

The USPSTF’s recommendations are considered the “gold standard” for determining which clinical services are preventive. They review and look at various screening tests and preventive medications to determine whether there’s proof these interventions work and that the benefits they provide outweigh the potential harm. USPSTF indicates how strongly it recommends a particular method with a letter grade designation (A, B, C, D, and I). An A recommendation means that USPSTF strongly recommends that doctors provide a particular service to eligible patients. A B rating is simply a recommendation. A C means the task force recommends against routinely providing the service, but leaves the decision to the discretion of the individual doctor and patient. A D rating means the group recommends against providing for a particular intervention. An I recommendation indicates that there is not enough evidence to determine whether to recommend for or against a particular procedure.

The USPSTF recommendations tend to be the most conservative of any national organization, because they look for interventions that have proven benefits backed by research. Therefore, promising new technologies and tests that are yet unproven (and at times remain unproven or shown to be no better than existing tests) will not be recommended. As a result, the USPSTF’s guidelines may lag behind those of other organizations. But because they set such a high standard before recommending a particular treatment, insurers should cover the tests and procedures rated A and B.

From the November 2009 update on breast cancer screening update, the USPSTF recommended:

• Against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
  

• Recommended biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.
  

• Against teaching breast self-examination (BSE). Grade: D recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  

• Insufficient evidence to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

What does this mean for women?

First, that there is some evidence that screening between ages 40 to 49 for breast cancer among women with average risk may not be as beneficial as we previously thought. There has been evidence from other countries, like Canada, which have suggested that. However, it is highly unlikely that the American Cancer Society (ACS), being an advocacy group for cancer awareness will change their stance. They said as much with the following:

The USPSTF says that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. Yet USPSTF also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.

The American Cancer Society neglects to mention the potential number of extra women harmed with the extra screening between age 40 to 49. An additional 565 women need to be screened above and beyond the 1,339 women to save one life. Within this additional group, many women will have abnormal mammograms and require breast biopsies only to discover that the results were normal. The mammogram was a false-positive.

The USPSTF found in a study in the Annals of Internal Medicine, funded by the National Cancer Institute, that screening every other year achieved over 80 percent of the benefit of screening annually while cutting the false-positive result by nearly half. While every other year screening from age 50 to 69 years resulted in about a median 16.5% (range, 15% to 23%) decrease in breast cancer deaths compared to no screening, starting mammogram at age 40 decrease the death rate further by 3 percent, but increased the costs as more false-positive cases occurred. This article helped influence their recent decision.

Realistically for women, since ACS will not change their recommendation, is that mammograms will still be a covered benefit for any woman who desires to have a mammogram as early as age 40 and can be repeated annually.

What does this mean for you? If you are worried about breast cancer, consider getting screened starting at age 40, however, the benefit of screening may not be as good as we first thought. Certainly if there is a family history of breast cancer, you should discuss with your doctor whether mammography is enough or whether a breast MRI is needed.

Why are there conflicting information?

This won't be the first time USPSTF will have different recommendations than groups like ACS or other professional medical associations. Reasonable doctors and researchers can look at the same data and have different results. It speaks to the problem of screening for cancers and the tools that we currently have. The amount of precision that we would like as patients and doctors in identifying which group of individuals truly need a screening intervention and who does not have yet to be discovered. USPSTF and ACS disagree a bit on colon cancer screening as well. For example, when it comes to colon cancer screening USPSTF gives a grade A recommendation and suggests that:

Using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods may vary.

Yet, ACS also recommends virtual colonoscopy or stool DNA testing as reasonable alternatives even though there is no proof they save lives.

Stay tuned. Medical science continues to evolve and recommendations continue to change. The the mean time, exercise regularly, don't smoke, eat five servings of fruits and vegetables daily, and you might extend your life by an additional 14 years!

Your most crucial and trusted relationship is between you and your doctor. Questions? Speak up and ask. Don't be scared. Be informed.

Breast Cancer Awareness Month - Truths and Myths You Must Know

Besides being known for Halloween, the first full month of fall, and also a day to recognize Christopher Columbus, October is also known as breast cancer awareness month.

It not only is a good time to remind women to get screened for breast cancer, but also an excellent opportunity to clarify many myths that continue to persist among many women I meet in the office as well as community outreach programs I lead.

The lifetime risk of a woman developing breast cancer is one in seven. One common misconception is that breast cancer occurs primarily in women with a family history. In fact, the vast majority of breast cancers occur in women with no family history. The other misconception is that many women feel as they get older that their risk of developing breast cancer decreases. Their risk of breast cancer actually increases.

With increased awareness, thanks in part to the pink ribbons, the annual Susan G. Komen Race for the Cure, the breast cancer research stamp, and breast cancer awareness month, you would expect that women would be well informed about breast cancer. You’d think women would get regular mammograms, perform breast self-exams, and have regular clinical exams performed by physicians. An October 2005 article in the New England Journal of Medicine found that in fact mammography was largely responsible for the improvement in breast cancer survival over the past twenty-five years.

Despite this, women are not getting mammograms as suggested. In 2002, only 62 percent of women forty and older reported having a mammogram within the previous year. The number decreased to less than 40 percent in women without insurance. Another study showed that only two-thirds of women forty and older in New Hampshire received mammograms annually or biannually even though 97 percent had health insurance and over half (61 percent) were college educated.

Screening for breast cancer begins by doing a self breast examination monthly. Learn how to perform a breast self exam (BSE) correctly at www.komen.org/bse. To be completely thorough, also get a mammogram if it is indicated for your age group. Often, mammograms detect breast cancer at a much earlier stage and well before a lump is large enough to be felt by yourself or a doctor. Mammograms can also detect growths too deep in the breast to be felt by anyone. However, performing a breast self-exam regularly is equally as important, since some breast cancers cannot be identified by mammography.

Women are recommended to get mammograms annually starting at age forty. Make sure that your mammogram is performed by an accredited facility and the results are interpreted by qualified radiologists. Refer to the FDA Center for Devices and Radiological Health at www.fda.gov/cdrh and look for the mammogram program.

If you feel a lump, or your breast just doesn’t feel right to you, see your doctor right away even if you had a normal mammogram recently. Sometimes growths can occur and you may need another mammogram or other additional tests like an ultrasound.

Newer digital mammograms are on the horizon. Preliminary results have shown that these mammograms may be more effective in detecting tumors in women with dense breasts, who are not menopausal, or are under fifty years of age. And for women who do not fit into these categories, digital mammography was found to be equally as effective as traditional film-based mammograms.

In 2007, the American Cancer Society recommended breast MRIs as another way of screening for breast cancer in women who were considered high risk for developing the disease. (A lifetime risk of 20 percent or higher is considered high risk.) Your doctor has a variety of tools that can predict this risk. One is available from the National Cancer Institute at www.cancer.gov/bcrisktool.

If you are considered high risk, ask your doctor whether a breast MRI is right for you and whether your hospital can perform the test. It may be a while before your local MRI facility will have the appropriate setup and radiologists trained to interpret the breast MRI correctly. The breast MRI is to be used with a mammogram and should not replace mammograms. Women at high risk for breast cancer should consider getting both a mammogram and a breast MRI at age thirty. Women with a risk of 15 to 20 percent should ask their doctor whether a breast MRI is a good idea.

Regardless of whether you use traditional film-based or digital mammograms, if a mammogram is indicated for your age group get it done.

For more additional helpful insider tips you must know to keep well, get the easy to read book – Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.

MRI After Breast Cancer Diagnosis Increases Mastectomy Rate and Delays Care

A recent study presented at the 2008 American Society of Clinical Oncologists (ASCO) Breast Cancer Symposium questioned the need for breast MRI on patients recently diagnosed with breast cancer. The abstract “the influence of routine pretreatment MRI on time to treatment, mastectomy rate, and positive margins” was headed by Dr. Richard J. Bleicher, a breast cancer surgeon at Fox Chase Cancer Center, and tried to determine if having an MRI would be helpful for breast cancer patients. Increasingly more women seem to be getting them after the diagnosis.
Basically, is using the latest imaging technology helpful? Already, the American Cancer Society recommends that women at high risk of developing breast cancer, those with a family history or personal history of breast biopsy for example, get screening MRI in addition to mammography. Whether MRI can and should be used as a tool before breast surgery was the reason for the research. The study looked at 577 women, who were referred to the breast cancer clinic between July 2004 and December 2006. The average age of a woman in the group was 57 years old. Nearly 23% of the women had MRI. Women who received MRI were younger (52 years old) than those who did not (59 years old).
Researchers found that having a MRI appeared to delay treatment by nearly 25 days after the initial doctor evaluation. Patients who had a MRI were two times more likely to have a mastectomy rather than breast conserving therapy (BCT). Interestingly, the women who received MRI were not considered at high risk for breast cancer (family history of breast cancer or ovarian cancer) or for recurrence based on tumor size, staging, or pathology. It wasn’t clear to researchers why some women received MRI and why others didn’t.
Perhaps MRI was ordered to help surgeons prepare their plan for surgery. An ideal pre-surgical tool would help the surgeons and patients make better decisions prior any surgery so that an operation is only done one time. So, how did MRI do for breast cancer surgery? Having a MRI before breast cancer surgery made no difference in the likelihood another excision would be needed because the biopsy margins weren’t free of tumor and it didn’t decrease the chance that a lumpectomy would be needed to be converted to a mastectomy. In other words, MRI made no difference, even though intuitively you would think it would. After all, isn’t more information better?
The study concludes that, “our findings suggest that MRI should not be a routine part of patient evaluation for BCT. Greater efforts to define the limitations and appropriate use of breast MRI are needed.”
What does this mean for you? MRI for breast cancer surgery planning is not the standard of care, there is currently no evidence that it makes surgical outcomes better than without it, trying to obtain one can delay treatment by 25 days, and it can also increase your chances of having a mastectomy. Understand that the findings should be limited to those patients in their fifties and probably older. It is difficult to say whether the findings are applicable to younger women in their twenties and thirties as MRI has been found to be somewhat helpful in breast cancer screening and could possibly have a role in pre-surgical planning.
As has been demonstrated many times in medicine, don’t fall into the trap of always assuming the latest technology or test is any better than traditional therapies. As this study suggests, newer methods may actually delay care and result in more surgery (mastectomy) than initially intended. Always try to demand treatments and therapies that are evidence-based.
Read more from the abstract.

Could Tim Russert's Heart Attack Been Avoided?

Not a trivial or academic question. Time magazine identified the NBC's Meet the Press moderator and Washington bureau chief as one of the 100 most influential people in world in 2008. His loss at such a young age, 58, is tragic. His ability to make complex topics clear for the public and to ask the hard questions will be missed in this the most historic presidential races in American history.

But was his sudden passing and fatal heart attack an avoidable tragedy? His internist, Dr. Michael Newman, who is affiliated with George Washington Medical Center, noted that Mr. Russert died of a sudden coronary thrombosis, which can occur without warning. Mr. Russert had been diagnosed with asymptomatic heart disease which reportedly was well-controlled with medication and exercise. He passed a cardiac stress test in late April. It seems like he got the appropriate care.

Yet, our healthcare system only provides the right preventive care 55 percent of the time. What medical students know, lowering blood pressure, controlling cholesterol, and arranging age-appropriate cancer screenings, shown to save lives, are not done routinely in this country. The ability of doctors and insurance plans to provide this
basic fundamental care varies by about 20 percent. If one compared the safety performance of the top 10 percent of airlines with the national average, the quality gap was far less at less than 1 percent.

The National Committee for Quality Assurance (NCQA) estimates that had all doctors and insurance plans performed at the level of the nation's top 10 percent that 80,000 Americans, all who had health insurance, would have avoided premature death. That is twice the number of breast cancer deaths annually. A study of 20,000 patients in 12 US major cities found that only 68 percent of those with heart disease and only 65 percent of those with high blood pressure received the recommended care developed by expert committees.

Unfortunately, one can't assume that the best preventive care is done at university medical centers. A study in California found that the vertically integrated healthcare organization Kaiser Permanente outperformed both university medical centers and community hospitals in decreasing their patients' heart attack risk and death by 30 percent. The integrated VA healthcare system was also found to outperform community hospitals in caring for diabetics. It consistently ensured its patients got the right medications at the right dosages better that those in the communities around them.

It seems that as a country we take for granted the failings of the healthcare system which are occurring with alarming frequency. As we mourn the unexpected passing of a great journalist, we should instead ask ourselves whether there were systematic failures in the healthcare system that Mr. Russert relied on to keep him well? The goal wouldn't be to find negligence or to identify scapegoats, as like the aviation industry, the delivery of healthcare is too complex to simply isolate one person or entity that resulted in the mishap. It is very likely that General Electric, NBC's parent company, provided him with health insurance options that were accredited by NCQA as excellent in keeping people healthy.

Is it possible, however, that the recommended care wasn't delivered? As our nation struggles with how to make the healthcare system more affordable, accessible, and with higher quality, the debate boils down to who is best in determining the right care at the right time. Is the onus on patients? Does the responsibility rest on the healthcare industry? It is an important conversation our country must have and certainly would have gone better with a skilled moderator like Mr. Russert. He will be deeply missed.

Medicare Restricts Reimbursement for Anemia - Better Patient Care?

A recent FDA advisory committee recommended that anemia medications, Procrit, Epogen, and Aranesp be not used in patients with breast cancer, head and neck cancers and used in patients with incurable cancers. These anemia medications are typically used to support cancer patients, who develop anemia, as a result of chemotherapy. This most recent FDA recommendation follows research studies which reported last year that these medications may have caused more deaths and contributed to tumor growth.

From the article:

• In its efforts to overturn Medicare's new reimbursement policy, Amgen Corp. spent more than $16 million on lobbying last year and nearly $700,000 on campaign contributions, according to the Center for Responsive Politics. Amgen manufactures all three of the anemia drugs involved — Aranesp, Epogen and Procrit. Johnson & Johnson markets Procrit.
• The aggressive lobbying campaign succeeded in generating numerous letters and speeches from lawmakers denouncing Medicare's actions and in legislation that would have voided the rule if passed.
• Many doctors and consumer groups joined in the criticism last year when Medicare made its decision to restrict when it would pay for treatments. Amgen and J&J argued again Thursday that the safety problems cited by FDA have been inconsistently reported across dozens of studies. And they pointed out that only studies involving higher-than-recommended dosing levels showed significant safety risks.
• The two drug companies have asked for more leeway from Medicare to reimburse doctors for maintaining hemoglobin levels up to 12. The Congressional Budget Office estimated that overturning CMS's decision could increase government spending by as much as $5.3 billion over the next decade.

What is fascinating isn't the science behind this, but the outcry from doctors, lawmakers, and the public when Medicare decided last year only to reimburse doctors if the medications were administered to patients with a hemoglobin of 10 or less (hemoglobin is a measure of the amount of red blood cells). A hemoglobin of 10 was derived from the research that suggested patients given these medications with higher hemoglobins did worse. Although the manufacturers argued that perhaps doctors were administering the medications at higher than recommended levels, doctors generally don't change practice behavior based on medication label warnings as quickly as they do when reimbursement is decreased or no longer covered.

Naturally everyone has a financial stake in seeing this ruling overturned. The pharmaceutical companies will see sales of their medications decrease as there are fewer indications (note their consumer-directed ads about these medications). Doctors will have their reimbursement decreased because they also will have fewer patients to give this medication to, even though the science suggests that many of these patients not only shouldn't get this medication but also that they could do harm. Patients, aligned with their doctors, will see this as a takeaway. Lawmakers, focused on getting re-elected would rather be seen on the side of their constituents, patients and doctors, and lobby against the FDA or Medicare as again taking a valuable benefit away.

Yet, when all is said and done, the heroes in the process, those that are protecting patients by altering doctors' behaviors to comply with the latest in research and those that are protecting the taxpayers by assuring that we are paying for the right care, are buried by massive lobbying and public relations campaigns. Perhaps this is why our healthcare system is in crisis because at the end of the day it isn't about the science, but about where the money goes.

Health Net ordered to pay $9 million after canceling cancer patient's policy

An arbitration judge slapped for profit health insurer Health Net with a judgment of $9 million in favor of a breast cancer patient who had her policy canceled as she underwent chemotherapy. What is frightening is the case highlighted the shameful practices of for profit health insurers. This patient, who had other insurance prior to Health Net, appears to have been aggressively courted by its sales force to switch because it would save her money. It certainly didn't save her from grief as see was saddled with over $100,000 in medical expenses, stopped chemotherapy for months until she could find a charity to cover costs, and unnecessarily worrying about whether she could get the right care, even though in good faith she bought coverage to avoid all of this.

It is a worrisome trend in California, which could be a sign of things to come across this country. Insurers under pressure from employers to slow rising healthcare costs while also seeing double digit rate increases in medical expenses are trying to find ways to do both. Just skipping the ethical discussion of whether for profit insurers should be in the business of healthcare, as any household, business, and government that expects to do well should know, what you bring in (income or revenues) must be more than what you pay out (bills or expenses). It appears insurers are trying to cancel policies for patients, who don't disclose their medical conditions (known as pre-conditions) on their applications retro-actively. According to the LA Times article, Health Net, like many other insurers do so because it is "necessary to hold down costs by weeding out people who may have failed to disclose pre-existing conditions on applications for coverage. They say cancellations happen infrequently." Wellpoint, one of the nation's largest for profit insurers is in favor of changing this practice as is Health Net. Blue Shield had no comment.

Health Net argued that they would have never provided coverage had they known about her weight and her use of fen-phen, a dietary drug that was shown to increase the risk of heart valve problems and pulmonary hypertension which can be fatal. Although obesity can increase the risk of breast cancer, there was nothing to her history to indicate a personal or family history of breast cancer.

What does this mean to you? While the practices illustrated in this case clearly are very disturbing, particularly giving bonuses to staff for meeting a set goal of revoking policies, it shows that insurers are having a difficult time balancing astronomical healthcare expenses and the inability to raise premiums to cover this. As a result, they are more aggressive and critical about who to insure. Without healthcare reform, it is easy to see what will happen. Those with even the slightest problem, like being overweight or obese, will be denied coverage. Those with existing medical problems won't be able to get coverage at all. In fact, ironically the only people who will be able to get coverage are the young and healthy, the group of people that can't afford coverage or are not required to have coverage to offset those who are ill. The underlying premise of insurance, that all chip in to cover those who have an adverse outcome, does not apply in the healthcare industry.

It is clear that there will be fewer insurers as weaker ones drop out of providing health insurance. But unless insurers can balance the revenue and expense equation, the end of the story is simply this, the government will step in and need to provide either financial guarantee and backing like they do for flood insurance or complete government takeover of the insurance industry. It's easy to bash insurance companies and their egregious behavior should not be condoned or tolerated, but is it a sign of how desperate the situation is in our healthcare system which is the most dysfunctional in the world?

What You Must Do to Stay Healthy

The American healthcare system only consistently delivers the right preventive care 55 percent of the time. As a result, tens of thousands of Americans die prematurely from avoidable deaths because simple interventions weren't done. Doctors are increasingly busy and may not have enough time to tell you all you need to know to stay well. One study showed that a doctor working full time would need an extra day to counsel patients on what steps they should do to keep healthy. As a result preventive screening tests for cancers like breast cancer, prostate cancer, and colon cancer, which are leading causes of death, aren't performed routinely and regularly for those who need it. With more patients paying higher deductibles and co-pays, you must know what you should ask for and then get it done.

For breast cancer screening, this means women at average risk should have a mammogram at age 40. Men at average risk should begin screening for prostate cancer at age 50. Both genders should have colon cancer screening, either a sigmoidoscopy with annual stool testing or a colonoscopy starting at age 50. You may need to check with your doctor if you are at higher risk as you may need to be screened earlier or more frequently. A major misconception is that only individuals with a family history are at risk for cancer. While they are at higher risk, the vast majority of new cancer cases occur in individuals without a family history.

The same preventive screening tests and interventions also apply to other problems like high blood pressure, high cholesterol, and diabetes. Do you know what the ideal blood pressure is? How often should you have it checked? When should you be screened for diabetes? Are you at risk?

Even if you exercise regularly, are at a healthy weight, don't smoke or drink, it doesn't mean you can or should skip these important preventive steps. Identifying and addressing problems early increases your chance of living longer and staying well.

The healthcare system doesn't reliably remind you when you should get these tests done. Your doctor may not have enough time to remind you what to do. Increasingly you are paying more for healthcare. Find out what you need to do to stay well. It's your money. It's your life.

Go to www.davisliumd.com to get the preventive guidelines for adults under the free download section.

Healthcare Failings Due to Not Doing the Basics

For anyone interested in understanding what drives a lot of the costs in the healthcare system, the New York Times health series about the six killers in America, heart disease, cancer, stroke, chronic obstructive pulmonary disease (emphysema), diabetes, and Alzheimer's is an excellent place to start.

Some themes begin to emerge. For heart disease, the way to prevent future heart attacks is to ensure that patients understand how to take their medications and that it is often for life. For successful cancer treatment, the goal is early detection and undergoing the simple, but for some, unpleasant tests to screen for breast, colon, and prostate cancer. For stroke, it is to ensure that missed opportunities aren't missed.

Ulimately, much of the differences between a fair outcome and great outcome is focusing on the little things - taking medications regularly and as directed, getting the preventive screening tests done, and making sure that the little things are always taken care of.

Much like any coach knows before a team can be successful, each of the players must know the fundamentals. In hockey that would be skating, stickhandling, passing, and checking. It doesn't matter how expensive your skates are or what high tech materials your stick is made out of. Unless you and your team know the basics, you will fail. Unfortuantely, the healthcare system as a whole hasn't yet mastered the fundamentals.

Breast Cancer and Colon Cancer Treatment and Survivorship Guides -- A Good Idea

The American Society of Clinical Oncologists (ASCO) last month announced that they would have suggested treatment plans and summaries for breast cancer and colon cancer care as well as a survivorship plan available on their website. The former is for oncologists and the latter is for their patients. The treatment plan and summary, which consists of two pages will help oncologists summarize and review important clinical information and well as pre and post chemotherapy information to make it easier to deliver care. These forms were not intended to replace the usual detailed medical documentation, history taking, physical examination, and assessments that oncologists already were accustomed to doing.

While it remains to be seen how doctors will feel about the treatment plan and summary forms, breast cancer as well as colon cancer patients will like the one page survivorship plan. Treatment of cancer is already a complicated and potentially confusing process with many different treatments, dates treatments are given, and when the various office visits and follow-up tests are needed. The survivorship plan provides a basic road map so that an individual patient will have a basic idea of what to expect over the next few weeks, months, and years. It was recommended that the details of the plan should be tailored to the individual's unique circumstances.

This initial effort is a step in the right direction. With doctors busier and more rushed than in the past and patients faced not only with the emotional impact of coping with cancer as well as the logistical challenges of getting treatment, these forms provide a starting point of conversation between oncologists and patients. Already ASCO is working on developing treatment summary plans and survivorship plans for other cancers.

If you or a loved one has been recently diagnosed with breast cancer or colon cancer, download the relevant survivorship plan (and even the treatment plan and summary form) and bring it to your oncologist. It can only help you navigate through what is often a trying and confusing time.