Sunday, March 28, 2010

Is healthcare a right or a privilege?

Is healthcare a right or a privilege?

Depending on how you view this determines how you feel about the recent healthcare reform which was signed by President Obama.

As a doctor, I firmly believe that having healthcare is a right.

As a nation, we agree that individuals should be accountable for their actions. People often argue that those who are reckless with their bodies by ingesting chemicals via cigarettes or drug use and who subsequently develop cancers shouldn't be subsidized by others insurance premiums as the latter group works hard at staying healthy by exercising, maintaining an acceptable weight, and eating generous portions of fruits and vegetables. Some how it isn't fair.

Unfortunately life and good health aren't quite that easy or predictable.

Children who haven't had time to abuse their bodies do develop cancers, type 1 diabetes requiring insulin, or are born with genetic problems, like cystic fibrosis, that require expensive medical therapies that potentially are lifelong. Once diagnosed, these children are now plagued with the "pre-existing" label and unable to get health insurance. Over the past many years, the leading cause of personal bankruptcy for individuals and families is due to medical expenses. As a parent with an ill child could you simply walk away?

Non-smokers do develop lung cancer (note Dana Reeves, Christopher Reeves' wife). Individuals without a family history do get afflicted with other aliments. Healthy people do get heart attacks.

In other words, life happens. Good health can require a little luck as well. While individually one can decrease risk by not smoking, eating healthy foods, losing weight, and exercising, it isn't a sure thing. Bad things can happen to good people.

About 1 in 10 Americans or thirty-two million citizens, roughly the entire population of Canada, don't have health insurance . As a country, is it acceptable for us to walk away from them?

Even today, Americans believe in the American dream - work hard and you can be successful. The wild card is that having good health can be a finicky thing. Do everything right and you could or a family member could be stricken with a serious illness. Prior to healthcare reform, this situation not only could bankrupt you but your family.

Let's be clear. The legislation isn't perfect. It isn't so much true healthcare reform, but health insurance reform. The program phases in over a number of years. It doesn't address healthcare delivery or costs, which will likely occur in 2011. Nevertheless, it is an important start.

Despite the heated rhetoric from both parties, Americans are still a society that welcomes diversity, provides compassion and help to fellow human beings, believes in justice, fairness, and the opportunity to succeed with dogged hard work. This healthcare reform legislation, though far from ideal, is a good first step to ensure the American dream can still exist for current and generations to come.

Thursday, March 4, 2010

The truth about prostate cancer screening

Earlier this month, the American Cancer Society revised its recommendation for men regarding prostate cancer screening based on the latest research. Specifically ACS wanted men to ask their doctors about the limitations of PSA blood testing and digital rectal exams and their inability to improve survival.

Based on the National Cancer Institute's Prostate, Lung, Colorectal, and Ovarian screening trial and the European Randomized Study of Screening for Prostate Cancer, there was no evidence that screening with PSA made a difference in decreasing death from prostate cancer after a follow-up of seven years. While the European study showed a slight decrease in mortality with screening, this did not occur until about after nine years of follow-up. In other words, if this testing is helpful perhaps it will take until a ten year follow-up, before a decrease in prostate cancer rate is seen. Time will tell as the PLCO screening trial is still ongoing.

For now the American Cancer Society (ACS) recommends that men who are average risk (no family history or are not African American) should have a discussion with their doctors at age 50 about the limitations of PSA and rectal exams to find prostate cancer. If patients are unable to make a decision, then ACS suggests that doctors to the following:

After this discussion, those men who want to be screened should be tested with the prostate specific antigen (PSA) blood test. The digital rectal exam (DRE) may also be done as a part of screening.

  • If, after this discussion, a man is unable to decide if testing is right for him, the screening decision can be made by the health care provider, who should take into account the patient’s general health preferences and values.
  • Men who choose to be tested who have a PSA of less than 2.5 ng/ml, may only need to be retested every 2 years.
  • Screening should be done yearly for men whose PSA level is 2.5 ng/ml or higher.

What to make of all of this? Medical research is constantly evolving. The more scientists investigate and study what works and what doesn't then the more precise doctors can figure out what must be done to keep you healthy. Despite public service announcements, prostate cancer screening has always been more controversial than screenings for other cancers because it wasn't clear that early detection made a difference. Certainly the most recent findings do nothing to change that sentiment.

For ACS, an organization focused on improving Americans' awareness to screen for cancer, to essentially tell men not to get prostate cancer screening demonstrates how unconvincing the evidence is that testing allows men to live longer. Another important learning is that patients need to understand that we still have a long way to go until we, doctors, have the tools to make precise diagnoses on which individual has an aggressive form of prostate cancer that requires medical intervention before becoming deadly and which others cancers are too small or slow growing to make a difference in a man's life.

Based on the latest evidence it is possible that with screening you might be diagnosed with prostate cancer, receive treatment that may include surgery or radiation which can result in impotence or urinary incontinence, as you and your doctor believe you've done the right thing to keep your self well. It is equally likely, however, that all of the interventions, treatments, pain, and complications you subjected yourself to made absolutely no difference.

So before you get a panel of blood work for a physical, ask your doctor if prostate cancer screening is proven to save lives. If he says yes, then you might want to print this out and ask him to explain the PLCO findings because you don't want to do more if it makes no difference it allowing to you live longer and healthier.


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