Tuesday, March 19, 2013

The Uninsured

A.C. is a 60 year old uninsured white female who recently was seen in my clinic.  She was referred for assessment of a new palpable right breast mass which had initially been imaged at an outside institution.  When the institution wanted $2000 to perform a biopsy on this suspicious mass, A.C. was referred to us because we have programs to cover the cost of imaging and biopsies for uninsured women.

M.G. is a 35 year old woman whom I saw this week, one year after her surgery to remove a malignant right breast mass.  She was initially imaged in April, 2011 at an outside institution, but, because she was uninsured and not a legal resident, it took her six months to find us to have her mass biopsied and eventually removed.  By the time she had her surgery, her mass had more than doubled in size and multiple lymph nodes under her right arm had cancer in them.

When I worked at my previous position, a patient had to quit her job in the middle of treatment for her breast cancer because the chemotherapy made her too sick to work.  When she quit her job, she lost her insurance and she stopped her cancer treatment.  When she returned to my clinic a year later after re-gaining her job and her insurance, her cancer had spread.

I recently met a young, white female conservative at a social gathering and, while she said she agreed with my 'liberal' social views, she stated that she 'belonged to the other side.'  When I asked her what she meant, she said that she didn't believe that people should 'be given something for nothing.'  What flashed in my head was the phone call I had made earlier that day to A.C. to tell her that she had breast cancer.  I could only get ahold of her between 3pm and 4pm.  Why?  Because that is the only time she had between her two full-time waitressing jobs, neither of which provided benefits.  She was only able to get the biopsy done because of our assistance programs for uninsured women.

There is something seriously wrong when we, members of the richest country on the planet, allow fellow citizens (and, yes, noncitizens) to suffer the consequences of undiagnosed or untreated disease simply because their situation doesn't allow for the safety net of medical insurance.  The amount of unnecessary suffering is heartbreaking.  All three of the examples above were dedicated, hardworking women who wanted to take care of themselves, who wanted to make the right decisions.  They weren't 'takers' or 'moochers,' just in need.

Although far from perfect, The Affordable Care Act will have the effect of mandating medical insurance for millions of people who currently are uninsured and are at the mercy of an often heartless and inaccessible system.  Although most economists believe that a single payer system is the best (this is also my opinion with Medicare, Medicaid, the military, TRI-CARE, S-CHIP and the Federal Employees Health Benefits system as multiple examples), taking the first wobbly steps towards this with The Affordable Care Act is the right thing to do.  You can read some questions and answers about The ACA here.

Part of the reason I took my current job almost five years ago is that part of the mission of St. Joseph Hospital is to serve the underserved.  This usually means poorer, uninsured patients, many of whom are undocumented.  Every year, we compete for grants and work with state funds to provide these vital services to these patients who would otherwise have no other options.  Politics aside, we as a country must figure out how to ensure coverage for all patients regardless of their ability to pay.  If these means more taxes for those of us who can afford it, then that is the price we pay for a stable, healthy, educated and safe population.  This is the moral, ethical and right thing to do.

We all benefit from a healthy, educated and safe workforce.  Doing what I do at the Breast Care Center at Exempla St. Joseph Hospital helps me keep the Hippocratic Oath I made when I graduated medical school nearly 21 years ago and helps to ensure that I, First, Do No Harm.  

Friday, September 28, 2012

Mammography Saves Lives!

I have been reading screening mammograms and diagnosing curable cancers for about 15 years now.  The benefits of mammography screening have never been in doubt in my mind.  Yet, about every ten years or so, much ado is made about someone's claim that they are less effective (or, in some cases, completely useless) than previously thought.  When a new doubt is raised, it causes concern and confusion in the minds of both patients and their referring providers.

This is not how it should be.

The main test of a mammography's ability to detect disease early enough to alter the course of that disease were Randomly Controlled Trials (RCTs) performed 30-50 years ago.  In these trials, one randomly assigned group was offered mammography screening and the other group got 'usual care' which, back then, was essentially nothing unless she or her doctor found a lump.  Some women assigned to the screening group did not get screened (remember, they were just offered the screen) and some women in the 'usual care' group went outside of the study and got exams.  Nevertheless, all participants were counted in the group to which they were assigned.  These 8 or 9 trials were conducted in four countries between 1964-1980 and most lasted 4-6 years.

Even with then-technology which we would now consider woefully inadequate (essentially unusable), cross-contamination of the study groups and some serious concerns about the methodology of the two studies from Canada, analyses of all of the studies consistently showed at least a 20% reduction in the death rate from breast cancer.

Several things have changed since then.

First, we have now had over 20 years of widespread screening in most of the 'Western' world.  Dr. Laszlo Tabar from Sweden, was the principle investigator of two of the largest RCTs in Sweden and is a personal friend of mine.  He has followed his study patients for the last 20 years and has made a significant discovery:  most of the survival benefit of screening mammography took place in the last 10 years or so of screening.  What this means is this:  the benefit of screening mammography continues to increase the more times a woman is screened.

Second, studies have looked at women who have actually get screens (as opposed to merely being offered to be screened).  Among women who have actually gotten screened, the death rate from breast cancer has decreased by over 50%.  This is one of the main faults of the 2009 US Preventative Task Force recommendations against screening women in their 40s.  They looked at data among women offered to be screened, not actually screened.

Third, technology has vastly improved since those first screening studies.  Consider this:  non-digital mammography continuously improved over 20 years of utilization.  By the late 1990s, it was about as good as it could get.  A few years later, digital mammography was developed and, on the first day it was used, it was at least as good (and better in certain patients) as non-digital mammography.  And now, we're already considering a move to 3D digital mammography which may prove to be a significant improvement over current '2D' mammography.  This means detection of more curable cancers that can be seen on imaging before they can be felt.

Ever since the beginning of mass population screening in the mid-late 1980s, we have seen a continuous decline in the death rate from breast cancer.  This is true in both the 40-49 year age group as well as women 50 and over.  In fact, for the first time that I've seen, the estimate of U.S. breast cancer deaths for 2012 by the NCI is now less than 40,000.  Still an obscenely high number, but an important milestone nonetheless.  Most research has indicated that at least 2/3 of the survival benefit is from screening mammography with improved treatment accounting for the other 1/3.

The Affordable Care Act guarantees no-cost (no co-pays or deductibles) annual screening mammograms for all women 40 and older.  This took effect in August and applies to most policies made or renewed after the effective date.  This also applies to Medicare/Medicaid recipients.  You can read more about it here: http://www.healthcare.gov/news/factsheets/2010/07/benefits-for-women-and-children_.html

We are lucky to live in a progressive state like Colorado as we were a step ahead of the federal government by guaranteeing similar coverage when CO House Bill 10-1252 went into effect on January 1, 2011.  This bill requires all insurance companies doing business in the Colorado to guarantee annual screening mammography for all women 40 years old or older.

Mammography shouldn't be confusing.  It should be easy, covered and comfortable.  In future blogs, I'll talk more about the myths and facts of breast cancer screening and even how you can get your annual mammogram at a happy hour 'party!'

Until then...