Cancer Screening May Be More Popular Than Useful -

After decades in which cancer screening was promoted as an unmitigated good, as the best — perhaps only — way for people to protect themselves from the ravages of a frightening disease, a pronounced shift is under way.

Now expert groups are proposing less screening for prostate, breast and cervical cancer and have emphasized that screening comes with harms as well as benefits.

Two years ago, the influential United States Preventive Services Task Force, which evaluates evidence and publishes screening guidelines, said that women in their 40s do not appear to benefit frommammograms and that women ages 50 to 74 should consider having them every two years instead of every year.

This year the group said the widely used P.S.A. screening test for prostate cancer does not save lives and causes enormous harm. It also concluded that most women should have Pap tests for cervical cancer every three years instead of every year.

What changed?

The answer, for the most part, is that more information became available. New clinical trials were completed, as were analyses of other sorts of medical data. Researchers studied the risks and costs of screening more rigorously than ever before.

Two recent clinical trials of prostate cancer screening cast doubt on whether many lives — or any — are saved. And it said that screening often leads to what can be disabling treatments for men whose cancer otherwise would never have harmed them.

A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated.

Cancer experts say they cannot ignore a snowballing body of evidence over the past 10 years showing over and over that while early detection through widespread screening can help in some cases, those cases are small in number for most cancers. At the same time, the studies are more clearly defining screening's harms.

"Screening is always a double-edged sword," said Dr. Otis Brawley, the chief medical officer of the American Cancer Society. "We need to be more cautious in our advocacy of these screening tests."

But these concepts are difficult for many to swallow. Specialists like urologists, radiologists and oncologists, who see patients who are sick and dying from cancer, often resist the idea of doing less screening. General practitioners, who may agree with the new guidelines, worry about getting involved in long conversations with patients trying to explain why they might reconsider having a mammogram every year or a P.S.A. test at all.

Some doctors fear lawsuits if they do not screen and a patient develops a fatal cancer. Patients often say they will take their chances with screening's harms if a test can save their lives.

And comments like Dr. Brawley's give rise to other questions as well. Is all this happening now because of worries over costs? And in any case, is all this simply an academic argument, since most doctors, faced with real patients, still suggest frequent screening and their patients agree?

The answer, cancer experts say, is, to a certain extent, all of the above. But, they say, there does seem to be a change in the air. Researchers used to be afraid to even broach the subject of screening's harms.

"It was the third rail," said Dr. H. Gilbert Welch of Dartmouth Medical School. "We were afraid to say exactly what we thought for fear of seeming too crazy." It was easy to get financing to study the benefits of screening, he added, but a study that looked at harms was "too far out of the culture."

Not now, he said.

And with that change has come a new look at screening.

"No longer is it just, Can you find the cancer?" Dr. Brawley said. "Now it is, Can you find the cancer, and does finding the cancer lead to a decrease in the mortality rate?"

Then there is the new emphasis on cost.

The current issue of The New England Journal of Medicine, for example, has an article by two prostate cancer specialists who note that one recent study concludes that $5.2 million must be spent on screening to prevent one prostate cancer death. And, add the authors, Dr. Allan S. Brett of the University of South Carolina School of Medicine and Richard J. Ablin of the University of Arizona, that figure is not inclusive. The true cost is undoubtedly even greater.

"We believe that the current P.S.A.-based screening paradigm does not compare favorably with competing health care priorities," they wrote.

The cost of screening, said Dr. Russell P. Harris, a screening researcher at the University of North Carolina, "is one of the factors that is pushing toward a tipping point."

But, medical experts note, many people, including doctors, are confused by the changing message, which is understandable.

"You don't turn decades of thought around immediately," said Dr. Timothy J. Wilt, a task force member from the University of Minnesota.

In part, doctors and patients are stuck in a sort of cancer time warp. The disease was defined in 1845 by a German doctor, Rudolf Virchow, who looked at tumors taken at autopsy and said cancer is an uncontrolled growth that spreads and kills. But, of course, he was looking only at cancers that killed. He never saw the others.

"Now we are backing away from that," Dr. Brawley said. In recent years, researchers have found that many, if not most, cancers are indolent. They grow very slowly or stop growing altogether. Some even regress and do not need to be treated — they are harmless.

"We are going from an 1845 definition of cancer to a 21st-century definition of cancer," Dr. Brawley said.

Dr. Brawley, too, noticed that more people are starting to understand the limitations of screening, and its risks.

Change, though, has been slow in the face of intense promotion of screening by medical practices, hospitals and advocacy groups and years of misunderstandings about screening's benefits and risks.

"You've got all this positive stuff" about screening, Dr. Brawley said. "And you have been taught since you were on your mother's knee that the way to deal with cancer is to find it early and to cut it out."

Yet he is optimistic.

"I think people are actually starting to understand that we need to be a little more rigorous in what we accept about screening," Dr. Brawley said. "I do sense there is some movement there."

Doctors 2.0™ & You (May 23-24, 2012, Paris)

Doctors 2.0™ & You is an innovative conference examining how doctors use social media, mobile applications, and Web 2.0 tools to connect with patients, colleagues, hospitals, pharma, and government. The two-day Doctors 2.0 & You event will bring together healthcare and social media innovators and fans — healthcare professionals, patients, industry, government — from across Europe, the U.S.and the Rest of the World.

"Social Media and mobile applications are impacting healthcare, as no one had imagined even last year, whether through the bringing forward of new medical questions, new diagnostic tools, extending the reach of congresses, patient advocacy, and raising ethical issues. Usage is huge," notes Denise Silber, founder of Doctors 2.0 & You and President of Basil Strategies.

And yet little is known about how physicians actually use these tools, and the accompanying results, best practices, challenges and opportunities. The Doctors 2.0 & You agenda will shed light on topics such as the new physician-patient relationship, physician activity in online communities, eHealth start-ups, the relation to pharma and government. Interactive exchange among attendees will be facilitated via workshops, panels, posters, exhibits.

M.R.I.’s, Often Overused, Often Mislead, Doctors Warn -

Dr. James Andrews, a widely known sports medicine orthopedist in Gulf Breeze, Fla., wanted to test his suspicion that M.R.I.'s, the scans given to almost every injured athlete or casual exerciser, might be a bit misleading. So he scanned the shoulders of 31 perfectly healthy professional baseball pitchers.

The pitchers were not injured and had no pain. But the M.R.I.'s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. "If you want an excuse to operate on a pitcher's throwing shoulder, just get an M.R.I.," Dr. Andrews says.

He and other eminent sports medicine specialists are taking a stand against what they see as the vast overuse of magnetic resonance imaging in their specialty.

M.R.I.'s can be invaluable in certain situations — finding serious problems like tumors or helping distinguish between competing diagnoses that fit a patient's history and symptoms. They also can make money for doctors who own their own machines. And they can please sports medicine patients, who often expect a scan.

But scans are easily misinterpreted and can result in misdiagnoses leading to unnecessary or even harmful treatments.

For example, said Dr. Bruce Sangeorzan, professor and vice chairman of the department of orthopedics and sports medicine at the University of Washington, if a healthy, uninjured person goes out for a run, a scan afterward will show fluid in the knee bone. It is inconsequential. But in an injured person, fluid can be a sign of a bone that is stressed or even has a crack and is trying to heal.

"An M.R.I. is unlike any other imaging tool we use," Dr. Sangeorzan said. "It is a very sensitive tool, but it is not very specific. That's the problem." And scans almost always find something abnormal, although most abnormalities are of no consequence.

"It is very rare for an M.R.I. to come back with the words 'normal study,' " said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. "I can't tell you the last time I've seen it."

In sports medicine, where injuries are typically torn muscles or tendons or narrow cracks in bones, specialists like Dr. Andrews and Dr. DiGiovanni say M.R.I.'s often are not needed — they usually can figure out what is wrong with just a careful medical history, a physical exam and, sometimes, a simple X-ray.

M.R.I.'s are not the only scans that are overused in medicine but, in sports medicine, where many injuries involve soft tissues like muscles and tendons, they rise to the fore.

In fact, one prominent orthopedist, Dr. Sigvard T. Hansen, Jr., a professor of orthopedics and sports medicine at the University of Washington, says he pretty much spurns such scans altogether because they so rarely provide useful information about the patients he sees — those with injuries to the foot and ankle.

"I see 300 or 400 new patients a year," Dr. Hansen says. "Out of them, there might be one that has something confusing and might need a scan."

The price, which medical facilities are reluctant to reveal, depends on where the scan is done and what is being scanned. One academic medical center charges $1,721 for an M.R.I. of the knee to look for a torn ligament. The doctor who interprets the scan gets $244. Doctors who own their own M.R.I. machines — and many do — can pocket both fees. Insurers pay less than the charges — an average of $150 to the doctor and $960 to the facility.

Steve Ganobcik is something of a poster child for what can go wrong with the scans. A salesman who turns 44 on Saturday, Mr. Ganobcik twisted his knee skiing in Colorado in February. He continued skiing anyway and skied again the next two days as well, not wanting to cut his vacation short.

When he got home to Cleveland, his knee still bothered him, so he saw a sports medicine orthopedist. The doctor immediately ordered an M.R.I. and said it showed a torn anterior cruciate ligament, or A.C.L. It is one of the most common — and most devastating — sports injuries. The standard treatment is surgery, with a difficult recuperation lasting six months to a year.

Mr. Ganobcik looked into surgical techniques and decided he wanted a different one than the one his doctor offered. So he saw another sports medicine orthopedist who, agreeing that Mr. Ganobcik's ligament was torn, scheduled the operation.

Meanwhile, Mr. Ganobcik heard that Dr. Freddie H. Fu, chairman of the division of sports medicine at the University of Pittsburgh, had what might be an even better technique, so he went to see him.

To Mr. Ganobcik's surprise, Dr. Fu told him his ligament was not torn after all. His pain was from a fracture in a long bone in the lower leg that the other doctors had also noticed was broken. An M.R.I. at the University of Pittsburgh confirmed it, showing a perfectly normal A.C.L. (Dr. Fu adds that Mr. Ganobcik's original scans had an image that was ambiguous. He wanted a better one, to see if Mr. Ganobcik's ligament had been partly torn and was healing or had never been torn at all. He would not need surgery with a partial tear, but he would need more careful recuperation.)

Dr. Fu's suspicions were raised by Mr. Ganobcik's story. He could never have continued skiing with a torn A.C.L. The diagnosis "made no sense," Dr. Fu said.

And that, Dr. Fu says, illustrates a common problem: relying on an M.R.I. instead of a history and an exam. Dr. Fu's diagnosis "was a shock," Mr. Ganobcik said. "I thought he was going to talk about options for surgery."

M.R.I.'s can be extremely useful in sports medicine, said Dr. Andrew Green, the chief of shoulder and elbow surgery at Brown University. But, he says, there is a fine line between appropriate use and overuse.

That, at least, is what he found in one of the few studies to address the issue. The ideal study would randomly assign patients to have scans or not and then assess their outcomes. Such a study has not been done. Instead, a few researchers asked if scans made a difference for people who happened to have them. They found they did not — at least in two common situations.

Dr. Green and his colleagues reviewed the records of 101 patients who had shoulder pain lasting at least six weeks and that had not resulted from trauma, like a fall. Forty-three arrived bearing M.R.I.'s from a doctor who had seen them previously. The others did not have scans. In all cases, Dr. Green made a diagnosis on the basis of a physical exam, a history, and regular X-rays.

A year later, Dr. Green re-assessed the patients. There was no difference in the outcome of the treatment of the two groups of patients despite his knowledge of the findings on the scans. M.R.I.'s, he said, are not needed for the initial evaluation and treatment of many whose shoulder pain does not result from an actual injury to the shoulder.

Dr. DiGiovanni did a similar study with foot and ankle patients, looking back at 221 consecutive patients over a three-month period, 201 of whom did not have fractures. More than 15 percent arrived with M.R.I.'s obtained by doctors they had seen before coming to Dr. DiGiovanni. Nearly 90 percent of those scans were unnecessary and half had interpretations that either made no difference to the patient's diagnosis or were at odds with the diagnosis.

"Patients often feel like they are getting better care if people are ordering fancy tests, and there are some patients who come in demanding an M.R.I. — that's part of the problem," he said.

Some doctors might also feel they are providing better care if they order the scans, Dr. DiGiovanni said, and doctors often feel that they risk malpractice charges if they fail to scan a patient and then miss a diagnosis.

Dr. Hansen teaches his fellows — doctors in training — to be careful with scans and explains the risks of making the wrong diagnosis if they order them unnecessarily. He also knows it is not easy to refrain from ordering an M.R.I.

It's different for him, Dr. Hansen says. He is so eminent that patients tend not to question him.

"When I say 'You don't need a scan,' then it's over," Dr. Hansen said. His fellows get a different response. Patients, he says, "look at them like, 'You don't know what you're doing.' "

How much is that surgery in the window? - The Washington Post

We know that, in the aggregate, health care costs us a lot: about $2.5 trillion annually, or 17 percent of our gross domestic product.

But what about all the things that go into that $2.5 trillion? How much does each test, treatment and medical procedure actually cost? The Government Accountability Office recently tried to ask hospitals and doctors that question. It wanted to go beyond the numbers that insurance subscribers usually see, like the co-pays and deductibles associated with a given procedure, and get the total dollar cost. The agency didn't have much luck. 

Even with a number of health cost transparency efforts underway, it's still incredibly difficult to find out how much money is spent on specific medical treatments.

For its study, the GAO contacted 17 randomly selected hospitals to ask how much a knee replacement, a very common surgery, would cost. Here's what they heard back: "None of the hospital representatives could provide a complete cost estimate for a full knee replacement, meaning the price given was not reflective of any negotiated discounts, was not inclusive of all associated costs, and did not identify consumers' out-of-pocket costs."

Physicians did slightly better: when the GAO contacted 18 doctors to ask how much a diabetes screening would cost, four came up with a complete price estimate.

Health industry players are trying to make prices more transparent but not having huge success. The GAO surveyed eight health cost transparency efforts that range from an online Medicare tool to compare hospitals to a tool operated by the health plan Aetna, called the "Member Payment Estimator," that provides cost estimates for more than 500 physician and hospital services.

Across the board, the GAO review doesn't come up with much to celebrate. Only two provide an estimate of the total cost of a given episode of care.

There's a whole host of obstacles that stand in the way of transparent health care pricing. A big one has to do with health providers long considering health care costs proprietary. Both insurers and hospitals have strong business incentives not to publish health cost figures. "If a hospital was aware that another hospital negotiated a higher rate with the same insurance company, then the lower-priced hospital could seek out  higher negotiated rates which may eliminate the first hospital's competitive advantage," the GAO explains. On the flip side, insurers don't want their competitors to know if they're getting the same hospital services for a cheaper price.

This could start changing soon: 30 states are weighing legislation to increase price transparency in health care, according to a recent review in the New England Journal of Medicine. The end game of these initiatives isn't exactly clear. Would consumers change their health care behaviors if they had more information on cost? "Most patients are insured, so they pay very little of the cost of their medical care, which dramatically weakens or eliminates their incentive to choose a lower-cost provider," Harvard's Anna Sinaiko and Meredith Rosenthal have written. Other factors, like quality and convenience, also play a role in our health care decisions. If state legislatures do start passing these laws, we might soon know more about how much cost matters when it comes to where Americans get care.

The Limits of Breast Cancer Screening -

Has the power of the mammogram been oversold?

At a time when medical experts are rethinking screening guidelines for prostate and cervical cancer, many doctors say it's also time to set the record straight about mammography screening for breast cancer. While most agree that mammograms have a place in women's health care, many doctors say widespread "Pink Ribbon" campaigns and patient testimonials have imbued the mammogram with a kind of magic it doesn't have. Some patients are so committed to annual screenings they even begin to believe that regular mammograms actually prevent breast cancer, said Dr. Susan Love, a prominent women's health advocate. And women who skip a mammogram often beat themselves up for it.

"You can't expect from mammography what it cannot do," said Dr. Laura Esserman, director of the breast care center at the University of California, San Francisco. "Screening is not prevention. We're not going to screen our way to a cure."

new analysis published Monday in Archives of Internal Medicine offers a stark reality check about the value of mammography screening. Despite numerous testimonials from women who believe "a mammogram saved my life," the truth is that most women who find breast cancer as a result of regular screening have not had their lives saved by the test, conclude two Dartmouth researchers, Dr. H. Gilbert Welch and Brittney A. Frankel.

Dr. Welch notes that clearly some women are helped by mammography screening, but the numbers are lower than most people think. The Dartmouth researchers conducted a series of calculations estimating a woman's 10-year risk of developing breast cancer and her 20-year risk of death, factoring in the added value of early detection based on data from various mammography screening trials as well as the benefits of improvements in treatment. Among the 60 percent of women with breast cancer who detected the disease by screening, only about 3 percent to 13 percent of them were actually helped by the test, the analysis concluded.

Translated into real numbers, that means screening mammography helps 4,000 to 18,000 women each year. Although those numbers are not inconsequential, they represent just a small portion of the 230,000 women given a breast cancer diagnosis each year, and a fraction of the 39 million women who undergo mammograms each year in the United States.

Dr. Welch says it's important to remember that of the 138,000 women found to have breast cancer each year as a result of mammography screening, 120,000 to 134,000 are not helped by the test.

"The presumption often is that anyone who has had cancer detected has survived because of the test, but that's not true," Dr. Welch said. "In fact, and I hate to have to say this, in screen-detected breast and prostate cancer, survivors are more likely to have been overdiagnosed than actually helped by the test."

How is it possible that finding cancer early isn't always better? One way to look at it is to think of four different categories of breast cancer found during screening tests. First, there are slow-growing cancers that would be found and successfully treated with or without screening. Then there are aggressive cancers, so-called bad cancers, that are deadly whether they are found early by screening, or late because of a lump or other symptoms. Women with cancers in either of these groups are not helped by screening.

Then there are innocuous cancers that would never have amounted to anything, but they still are treated once they show up as dots on a mammogram. Women with these cancers are subject to overdiagnosis — meaning they are treated unnecessarily and harmed by screening.

Finally, there is a fraction of cancers that are deadly but, when found at just the right moment, can have their courses changed by treatment. Women with these cancers are helped by mammograms. Clinical trial data suggests that 1 woman per 1,000 healthy women screened over 10 years falls into this category, although experts say that number is probably even smaller today because of advances in breast cancer treatments.

Colin Begg, head of the department of epidemiology and biostatistics at Memorial Sloan-Kettering Cancer Center in New York, said that he supports mammography screening and believes that it does save lives. But he agrees that many women wrongly attribute their survival after cancer to early detection as a result of mammography.

"Of all the women who have a screening test who have breast cancer detected, and eventually survive the cancer, the vast majority would have survived anyway," Dr. Begg said. "It only saved the lives of a very small fraction of them."

The notion that screening mammograms aren't helping large numbers of women can be hard for many women and breast cancer advocates to accept. It also raises questions about whether there are better uses for the hundreds of millions of dollars spent on awareness campaigns and the $5 billion spent annually on mammography screening.

One of the reasons screening doesn't make much difference is that advances in breast cancer treatment make it possible to save even many women with more advanced cancers.

"Screening is but one of the tools that we have to reduce the chance of dying of breast cancer," Dr. Esserman said. "The treatments that we have actually make up for a good deal of the benefits of screening."

The Dartmouth analysis comes two years after a government advisory panel's recommendations to scale back mammography screening angered many women and advocacy groups. The panel, the United States Preventive Services Task Force, advised women to delay regular screening until age 50, instead of 40, and to be tested every other year, instead of annually, until age 74. The recommendations mean a woman would undergo just 13 mammograms in her lifetime, rather than the 35 she would experience if she began annual testing at age 40.

But the new recommendations have scared many women who believe skipping an annual mammogram puts them at risk of finding breast cancer too late. But Donald Berry, a biostatistician at M.D. Anderson Cancer Center in Houston, said adding more screening is not going to help more women.

"Most breast cancers are not lethal, however found," Dr. Berry said. "Screening mammograms preferentially find cancers that are slowly growing, and those are the ones that are seldom deadly. Getting something noxious out of the body as soon as possible leads women to think screening saved their lives. That is most unlikely."

Dr. Love, a clinical professor of surgery at the David Geffen School of Medicine at the University of California, Los Angeles, says the scientific understanding of cancer has changed in the years since mammography screening was adopted. As a result, she would like to see less emphasis on screening and more focus on cancer prevention and treatment for the most aggressive cancers, particularly those that affect younger women. Roughly 15 percent to 20 percent of breast cancers are deadly.

"There are still 40,000 women dying every year," Dr. Love said. "Even with screening, the bad cancers are still bad."

For breast cancer survivors, a long road back to 'normal' -

For Elissa Bantug, one of the scariest moments of her breast cancer treatment was the day it ended.

"I thought finishing treatment was going to be a celebration," says Bantug, 29, who was diagnosed at 23 as a single mother. "When I had radiation after my lumpectomy, I was counting down treatments like a child counting down the number of days of school."

When daily therapy ended, however, Bantug felt cast adrift. For the first time in months, no one would be monitoring her for signs of a relapse. During active treatment, "every day, there was somebody examining me, and every day, the nurses were asking about side effects," Bantug says. "When I asked my oncologist 'When do I see you next?' he said, 'You don't.' He said, 'Have a nice life.'"

Like many cancer survivors, Bantug had questions about staying healthy and recovering from toxic therapies that often leave women infertile. When she returned to her primary-care doctor for advice on preventing a recurrence, "he was really clueless. He said, 'Well, what did your oncologist say?'"

But it was hard to return to normal life, she says. Treatment left her in pain, exhausted, unable to sleep, depressed and anxious; it took 18 months to "really feel whole again."

Two-thirds of cancer survivors have trouble sleeping, even two years after treatment, found a study presented last year at a meeting of the American Society of Clinical Oncology. Up to 30% of breast cancer survivors suffer from persistent fatigue, says Julienne Bower, an associate professor at UCLA. Many also suffer from "chemo brain," a common term for post-cancer memory problems.

"We do a really good job of removing the disease but are not really good at getting people well," says Bantug, who now coordinates the Johns Hopkins Breast Cancer Survivorship Program in Baltimore, part of a national effort to address cancer survivors' long-term needs. The American College of Surgeons now requires accredited hospitals to provide follow-up care plans and make rehab available.

Rhode Island recently announced it will work with a company called Oncology Rehab Partners to provide rehab to patients; it is the first statewide program of its kind.

"It's not OK to just tell patients they have accept a new normal," says Julie Silver, a survivor and assistant professor at Harvard Medical School who started the company. "They should not have to live with more pain and disability than they need to." Patients treated for head and neck cancer may need speech and swallowing therapy, for example, she says.

A 2008 study in the Journal of Clinical Oncology found that 90% of women with metastatic breast cancer could benefit from rehab, but only 30% got it. "Study after study shows that cancer survivors are distressed not because of the diagnosis, but because of their inability to function," Silver says.

And while almost all breast cancer patients would like a care plan, when they are discharged, only 10% received one, found a new survey of 1,000 breast cancer survivors from the Cancer Support Community. Nearly 90% reported a social, physical or emotional issue that posed a moderate to very severe problem. The results show that doctors need to begin screening and monitoring patients for these problems at diagnosis, says Kim Thiboldeaux, the Cancer Support Community's president.

Silver notes that cancer patients have unique needs for rehab. Unlike someone who has a heart atttack and arrives at the hospital near death, cancer patients are often diagnosed when they still feel quite healthy. Treatment, however, can be incapacitating.

"I actually felt great going into treatment," says Silver, who was diagnosed at age 38. After surgery and chemotherapy, Silver says she was in pain and "sicker than I had ever been. I was done, and it was like, 'OK, you're ready to go back to work.' There was no way I was ready to go back to work."
Researchers don't know why such problems are so common. Chemo may cause fatigue by damaging heart muscle or memory problems by killing stem cells in the brain, says Robert Weinberg of MIT.

New research suggests survivors who suffer from fatigue are more likely than others to have immune abnormalities, Bower says. It's possible their immune systems kicked into overdrive during radiation and chemo but never went back to normal.

"Something got out of whack during breast cancer treatment, so their immune system doesn't reregulate," Bower says.

Scientists are studying a variety of possible treatments, from drugs that selectively turn off inflammation, to yoga and tai chi, which may influence the immune system by relieving stress. Cancer survivors who took a four-week yoga class were twice as likely as others to say their sleep improved.

Bantug says she has faced her worst fears about life after cancer. One year after she finished treatment, she found a new lump in her breast and had a double mastectomy.

Yet she calls herself lucky. After chemo, she worried she couldn't have another child; today, she is married and has two girls, one 13, born before cancer, another age 2, born after.

"I feel great," says Bantug, who has begun competing in triathlons. "It took a long time to get here, though."

Saks Institute for Mental Health Law, Policy, and Ethics

The Saks Institute for Mental Health Law, Policy, and Ethics is a think tank founded to foster interdisciplinary and collaborative research among scholars and policymakers around issues of mental illness and mental health. As a research institute, the goal is to study issues at the intersection of law, mental health, and ethics as well as influence policy reform and advocacy actions for improved treatment of people with mental illness. Ultimately, an interdisciplinary approach to these important issues will promote a society of well-rounded persons who work with deep satisfaction and integrity and enjoy a clear mind.

Elyn R. Saks’s Memoir on Schizophrenia Inspires Others -

Researchers have long wondered how some people with schizophrenia can manage their symptoms well enough to build full, successful lives. But such people do not exactly line up to enroll in studies.

For one thing, they are almost always secretive about their diagnosis. For another, volunteering for a study would add yet another burden to their stressful lives.

But that is beginning to change, partly because of the unlikely celebrity of a fellow sufferer. In 2007, after years of weighing the possible risks, Elyn R. Saks, a professor of law at the University of Southern California, published a memoir of her struggle with schizophrenia, "The Center Cannot Hold." It became an overnight sensation in mental health circles and a best seller, and it won Dr. Saks a $500,000 MacArthur Foundation "genius" award.

For psychiatric science, the real payoff was her speaking tour. At mental health conferences here and abroad, Dr. Saks, 56, attracted not only doctors and therapists, but also high-functioning people with the same diagnosis as herself — a fellowship of fans, some of whom have volunteered to participate in studies.

"People in the audience would stand up and self-disclose, or sometimes I would be on a panel with someone" who had a similar experience, Dr. Saks said. She also received scores of e-mails from people who had read the book and wanted to meet for lunch. She told many of them about the possibility of participating in a research project.

She now has two studies going, one in Los Angeles and another in San Diego, tracking the routines and treatment decisions of these extraordinary people. The movie producer Jerry Weintraub has optioned the book.

It has been a remarkable response, considering that the book was almost abandoned. Dr. Saks surveyed friends and colleagues for years before publishing it and got very mixed advice. Her husband was against it; the risks were too high. Academic colleagues warned her that coming out with a disorder as serious as schizophrenia could only harm her. "You want to be known as the schizophrenic with a job?" one said.

Her friend Stephen Behnke, director of ethics at the American Psychological Association, was supportive of her decision. "I remember talking about it just on the cusp of when she was going to send off the manuscript," Dr. Behnke said. "I said that we needed to sit down and make sure she was ready for this. It was like she was about to jump off of a cliff."

Jump she did. With the MacArthur money, she founded the Saks Institute for Mental Health Law, Policy and Ethics to study mental health and society. She is now working on another book, "Mad Women: A Most Uncommon Friendship," with the author Terri Cheney, who has written about her struggles with bipolar disorder.

"I was very lucky, being in academia, where people have been very accepting of this," Dr. Saks said. "Most people struggling to manage a severe mental illness do not have the luxury to do what I did."

When Doing Nothing Is the Best Medicine -

Don't just do something; stand there!"

It's one of those phrases that attending physicians will spout off to their medical students while on rounds, trying to sound both sagacious and clever at the same time. It sometimes grates, but it does make a valid point, because so much of medicine is about "doing something."

Sore throat? Prescribe an antibiotic.

New headache? Get a CT scan.

P.S.A. at the upper limit of normal? Get a biopsy.

Blood pressure still high? Add on another medication.

Doctors tend to want to "do something" whenever they note something amiss. And patients, by and large, want something done when they have a symptom. Few people like being told just to watch and wait.

Of course, every "thing" a doctor does also has side effects — rampant bacterial resistance from antibiotic overuse; major increases in radiation exposure from unnecessary CT scans; incontinence or impotence from prostate cancer treatments that may do nothing to prolong life; toxic drug interactions from multiple medications, particularly in the elderly.

The admonishment "Don't just do something; stand there!" reminds us that we should stop and think before we act, that there are many instances in which doing nothing is greatly preferable to doing something.

In fact, there are some doctors for whom "doing nothing" is the dominant way of thinking, who are not reflex "do-ers." They tend to lean toward the status quo: If the patient is doing fine right now, why rock the boat?

There's a term for this in the medical literature — clinical inertia — a term with a distinctly negative connotation. It describes the doctor who, for instance, sees a patient with cholesterol levels that are not optimum but who does not prescribe a statin. Or the doctor who notices that a diabetic patient's blood sugar levels are still not normal but refrains from increasing the patient's medication.

Of course, this is not black and white: There is a continuum of practice styles, just as there is a continuum of personalities in general. At one end are doctors who jump on the merest hint of a borderline lab value; at the other are doctors who avoid making changes unless absolutely necessary.

I like to think of myself as perfectly balanced in the precise middle of this spectrum, but if I take a hard look in the mirror I can see that I tend toward the clinical inertia side, always hesitating before I write a prescription or order a test. I tell myself that this arises from the august wisdom of my clinical experience, from having witnessed my fair share of side effects and adverse outcomes due to medical meddling. But I have to be honest and recognize that it reflects my personal tendency to be slow in making major decisions of any sort, to need a strong sense of how things are likely to play out before I act.

Every time I prescribe a medication — or order an invasive test, or refer a patient to a surgeon — it always feels like I'm placing a stone on a balance scale. Intellectually, my goal is to place the stone on the side of the scale that benefits my patient. But in my heart, I fear that it could end up on the other side, the side that harms, and the weight and permanence of the stone give me pause.

Many make the argument that deciding not to act is as momentous as deciding to act. Except that it never feels that way. My hesitation induces guilt; it makes me ask myself if I am harming my patients by not acting as fast or aggressively as some of my colleagues would.

An essay I came across in The Journal of the American Medical Association called "Clinical Inertia as a Clinical Safeguard" offered some food for thought. The authors postulated that doctors who tend toward inertia might actually benefit their patients by protecting them from overzealous medical intervention.

They focused on three common medical conditions — diabetes, elevated cholesterol and hypertension — for which there are established clinical guidelines for doctors to follow and "quality measures" that evaluate medical care. For all three illnesses, "lower is better" is the dominant mantra.

But while "lower is better" is probably true for large populations, that is not always the case for individual patients. In fact, there are some clinical trials in which aggressively lowered blood sugar or blood pressure have been associated with higher rates of dying.

The authors weren't saying that these medical conditions shouldn't be actively treated, but they did caution that standard clinical guidelines tend to favor overaggressive treatment in pursuit of "good numbers." In the stampede toward good numbers, individual patients can be harmed by the side effects of these treatments. Clinical inertia might actually act as a safeguard for such patients.

No one, of course, wants doctors who fail to act when action is necessary. And medical emergencies are a different story altogether. But most chronic illnesses, luckily, are not emergencies, so there is room for deliberation before action. And while insurance companies won't reimburse for deliberation, and report cards pointedly penalize, it's interesting to consider that there are many patients who may have been saved by inertia.

Danielle Ofri is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review. Her most recent book is "Medicine in Translation: Journeys With My Patients."

At Walgreen, Pharmacists Urged to Mix With Public -

CHICAGO — As the Walgreen Company pushes its army of pharmacists into the role of medical care provider, it is bringing them out from their decades-old post behind the pharmacy counter and onto the sales floor.

The pharmacy chain, based in Deerfield, Ill., and the nation's largest, has renovated 20 stores in the Chicago area and is converting more than 40 in Indianapolis to get the pharmacist closer to patients. Pharmacists in the revamped stores are being kept away from the telephone, where dealing with insurance coverage questions and other administrative tasks occupy 25 percent of their time, Walgreen says.

"What we are seeing now is pharmacists should be using their knowledge to help consumers manage their medications appropriately," said Nimesh Jhaveri, executive director of pharmacy and health care experience at Walgreen. "It's not about the product but the care we give."

The reinvention of the pharmacist's role comes at a critical time for Walgreen, as it vies to keep its customer base. The company has so far been unable to reach a new contract with the pharmacy benefit giant, Express Scripts. At the same time, Greg Wasson, the chief executive, is trying to remake the company into a national provider of health care services.

This last summer, Walgreen sold its own pharmacy benefit management company for more than $500 million to a Maryland firm in a deal that Mr. Wasson said would help the company focus on becoming the consumer's "most convenient choice for health and daily living needs."

Walgreen braced investors last month for the potential loss next year of more than $3 billion in sales in 2012 if it lost the customers whose prescription coverage was managed by Express Scripts. In the most recent fiscal year for the company, it filled about 90 million prescriptions managed by Express Scripts. The two are parting ways effective Jan. 1 over payment issues, leaving Walgreen scrambling to contract with major employers directly in hopes that they will want to opt out of Express Scripts' pharmacy network. Walgreen's new model resembles the type of service that CVS and other major drugstore chains are trying to achieve by developing deeper relationships with customers and their doctors. Big pharmacy companies are hoping to increase reimbursements from insurers and employers as they become more integral in managing customers' medical care.

At the newly converted Walgreen stores, one of the ways pharmacists hope to develop longstanding relationships with customers is through private or semi-private consulting areas away from the busy pharmacy counter.

On Chicago's North Side, Walgreen has a pharmacy in the Andersonville neighborhood on North Clark Street that dispenses a substantial amount of medications to patients with the AIDS virus, so privacy for patients was critical and figured in the overall idea behind the new store model, company executives said.

Behind the pharmacy counter, the familiar bags of medications are tagged and labeled alphabetically in plastic containers, but they cannot be seen from in front of the pharmacy counter. "Customers want privacy," Mr. Jhaveri said.

The Andersonville neighborhood store includes a 50-square-foot room behind sliding doors where a pharmacist, James Wu, can sit and counsel patients, who sit on a padded bench that has enough room for the patient and a family member or two. Mr. Wu's desk is steps to the right of the private room.

Mr. Wu said he could now spend more time talking to patients or out in the store aisles, and rarely is distracted now by the orders being placed for prescriptions.

"I would take calls, asking 'Is it ready?' 'Is it covered?' " Mr. Wu said. "The phone doesn't ring anymore."

Walgreen said it would route routine questions about insurance coverage and co-payment issues to a call center in Orlando, Fla., that is staffed around the clock by pharmacists and pharmacy technicians. Another new feature is a "health guide," a concierge of sorts who answers questions, markets new services and triages patients who may need other health care services, like treatment at a Walgreen Take Care retail clinic. At 354 of the chain's more than 7,700 stores, nurse practitioners at such clinics are available to handle routine maladies.

There are financial incentives for the more personal approach; some private and government insurers have programs that reward health care providers if they can prove that their services improve the quality of care and save money.

Moreover, insurance companies and the federal government are moving to models that encourage better coordination of medical care service, putting all providers on the same page.

Federal Medicare drug laws allow for payment to pharmacists for "medication therapy management," when patients have multiple chronic diseases like hypertensiondiabetes and asthma and are taking multiple medications. In recent years, Walgreen and other pharmacy chains have lobbied aggressively for reimbursement and changes to rules that allow pharmacists to do more and to get paid for these additional services.

Walgreen already has aggressive lobbying efforts under way to get pharmacists the ability under state rules to administer more vaccines in the pharmacy. And the company is working with doctors and hospitals to develop relationships that include having a pharmacist involved in patient consultations and management of their diseases.

"As we start to prove better outcomes, our reimbursement is going to be more based on how we do that," Mr. Jhaveri said.

Employers are open to Walgreen's idea, citing national studies showing large numbers of Americans, particularly among the elderly, who do not adhere to their treatment regimens or forget to take their medicines.

For example, 2009 research from the New England Healthcare Institute showed that patients who did not take medications as prescribed cost the health system $290 billion in "avoidable medical spending every year."

"There are a variety of reasons why the current medical system is failing to help people stay on their medications," said Larry Boress, president and chief executive of the Midwest Business Group on Health, a coalition of large employers that purchases more than $3 billion in medical care services annually. Among the members are Boeing, Ford Motor and Kraft Foods.

"On filling the script, the pharmacist or pharmacy tech doesn't do much more than ask: 'Do you have any questions?' And then they give you the bag," Mr. Boress said.

Parents Turn To The Internet Before Going To The ER | Fox News

One in eight parents goes online for medical information about their child's condition before taking the child to the emergency room, according to new research.

What's more, many parents would willingly visit sites recommended by their child's doctor—which means pediatricians should be prepared to offer advice on this topic, according to Dr. Purvi Shroff from the University of Louisville in Kentucky.

She presented her findings on Friday at the 2011 national conference of the American Academy of Pediatrics in Boston.

Dr. Shroff and her team interviewed 240 parents or guardians with Internet access who brought their child to the ER.
They found 12 percent of the parents had consulted the Web about their kid's trouble during the past 24 hours, while half said they had used the Internet at least once in the previous three months for a health-related question about their child.

The most common websites were WebMD and Wikipedia, but few parents used the Centers for Disease Control and Prevention website, run by the government, or the American Academy of Pediatrics' Healthy Children website.

The majority of parent Internet users said they were highly likely to visit a website that was recommended by their child's doctor.

"Being invested in your child's health and wanting to learn more and make the best decision for your child is always a good thing. However, when it comes to using the Internet, appropriate use depends on accessing good websites and knowing whether or not the information you find is applicable to your child," Dr. Shroff told Reuters Health.

It is important, she added, that parents be able to talk to pediatricians about what they read on the Internet, and for the pediatrician to place it in context for each child.

Prenatal testing: Birth defects often come as a surprise. - Slate Magazine

Here's something to freak out expectant parents:Over 2 percent of all American pregnancies are complicated by serious birth defects, and more than 0.5 percent of all fetuses have either a missing or an extra chromosome—a condition that leads to problems like Down or Edwards syndrome. Birth defects are a leading cause of infant mortality in the country, and most problems occur in pregnancies without any obvious risk factors. (For example, most babies with Down syndrome are born to women under 35 years of age.) There are ways to screen fetuses for birth defects like these, but due to a lack of clear guidance from caregivers or policymakers, parents may not find out about them until it's too late.
Knowing about problems before birth is important for at least two reasons. First, it allows doctors to treat the condition. Take heart problems, where a major artery may be connected incorrectly or a pumping chamber may be missing. Prenatal detection and immediate treatment at birth can prevent the sudden oxygen deprivation and shock that might occur if doctors were surprised by the defect. Some types of spina bifida can be surgically fixed before birth, preventing future paralysis.
A second benefit of prenatal screening is that it gives families a chance to decide whether they wish to continue a pregnancy at all. A huge number of women now choose abortion when faced with major birth defects. In Hawaii, which collects comprehensive information on pregnancy outcomes, more than 90 percent of women who learn they have a fetus with Down syndrome choose to terminate their pregnancies. (Other states are likely to have similar proportions.) Roughly one-half of all women whose babies have brain defects or major abdominal defects also elect abortion. To be sure, many families continue their pregnancies, and love and nurture their babies. Such families deserve support from doctors and insurers. But many families choose differently and they also deserve support.
Most of the time, however, expectant parents never realize there might be a problem. Major heart defects go unnoticed until birth an astounding 70 percent of the time. Three-quarters of all babies with missing limbs come as a surprise to both doctors and patients. More than one-half of cases of Down syndrome are overlooked. The list goes on and on.
Why are we missing so many important birth defects during pregnancy? Insurers and advisory groups don't support the necessary procedures. To diagnose the vast majority of problems—such as those related to the heart, lung, gut, and brain—one must visualize the fetus's body by ultrasound during the second trimester. But back in 1993, the New England Journal of Medicine reported results from the so-called RADIUS study (that's "Routine Antenatal Diagnostic Imaging with Ultrasound"). According to its findings, the blanket use of such ultrasounds "clearly indicate" no impact on a baby's outcome; parents would do just as well by letting their doctors decide whether to do the scans on a case-by-case basis. As a result, several insurance companies, such as Aetna, don't cover comprehensive fetal scans for routine pregnancies—a policy that affects roughly one-third of American women. The American Congress of Obstetricians and Gynecologists does not recommend the scan for all women, either. (When my wife was pregnant with our first child, our obstetrician actually advised us to make up a family history of birth defects, since our insurer wouldn't cover the scan in a normal pregnancy.)

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Hospital Infection Rates Drop, CDC Says -

Patients were less likely to get certain infections in U.S. hospitals last year thanks to a concerted campaign to prevent them, federal officials announced on Wednesday.

They found a 33 percent reduction in central-line infections – caused when a thin tube is inserted into a patient's neck or chest to deliver medication and check blood. Infections caused by catheters used to collect urine from bed-bound patients fell by 7 percent in 2010; surgical-site infections fell 10 percent; and dangerous methicillin-resistant Staphylococcus aureus, or MRSA, infections dropped 18 percent.

"It is very impressive progress," Dr. Denise Cardo, director of the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention, told a National Journal policy forum where she presented the figures.

The CDC, the Health and Human Services Department, and nonprofit groups such as the Association for Professionals in Infection Control and Epidemiology have been pushing to reduce infections in hospitals.

The CDC estimates that one in 20 patients -- 1.7 million a year -- will get some sort of infection while in the hospital. And 99,000 people die of these infections annually.  GE Healthcare released a report in July estimating that health care-associated infections cost at least $35 billion.

HHS developed its official "Action Plan to Prevent Healthcare-Associated Infections" in 2009, and CDC credits some of its goals with helping hospitals make the 2010 reductions.

"Timely progress has been made toward most targets for which associated data are available. Although this progress is promising, continued efforts are needed to achieve the goals in the Action Plan," the report reads.

One of the main goals is keeping data on hospital-acquired infections so that health care facilities can keep track of where they may be going wrong – and make note of when new practices such a using checklists start to turn things around.

"What gets measured gets managed," Linda Greene, director of infection prevention for New York's  Rochester General Health System, said at the forum.

Under the 2010 health care law, the Centers for Medicare and Medicaid Services will eventually stop paying for treating patients who get infected while in the hospital.

Cardo also credits groups such as Consumers Union, which has pushed for better collection of data on hospital infections and on policy measures to force health care facilities to act. "If it weren't for Consumers Union pushing for public reporting, we wouldn't be here now," Cardo said.

Health insurers are on board, too, trying to lower costs. America's Health Insurance Plans, the largest insurance-industry lobby group, reported in August on success stories in which hospitals were paid for meeting infection-control goals.

One program in Tennessee reduced central-line-associated bloodstream infections by 40 percent, AHIP reported.