When is 'cancer' not cancer?

In a recent article, Dr. George Lundberg, editor of Medscape General Medicine, cautioned that doctors and patients should distinguish between cancers that will likely be aggressive and "cancers" that will not.


Here is an interesting excerpt:

"Pathologists never can really predict how any one cancer will behave. But after many decades of matching histologic patterns with the natural history of diseases, we are actually pretty good at predicting which lesions will be really bad actors and which seem likely to lie around indolently.

"Starting about 1965, I practiced and taught that 'When you say cancer, you are saying a mouthful. Be very careful. By that diagnosis, you, the pathologist, are giving any clinician license to treat that patient and his or her cancer with whatever treatment might then be in vogue, including cutting it out, shooting ray guns at it, or poisoning the cancer and the patient.'
"...We are learning more every day that cancer is many different diseases, even thousands or tens of thousands of different diseases.
"For a long time, it made sense to try to eradicate all cancers, as early and as completely as possible..But, as with many exuberant efforts, this one got out of control. Many lesions that were called 'cancer' really were not cancers at all in behavior, and this fact began to be recognized in large numbers of patients. These unfortunate victims have experienced massive psychological and physical harm and costs without any clear benefits achieved by finding and treating their 'noncancers.' 

"Cure rates from aggressive therapy on those 'indolentomas' are 100%. But, so would the outcomes have been of nondiscovery---100% cure of nondisease."

Lundberg thanked Dr. Laura Esserman of the University of California-San Francisco and the National Cancer Institute for "recently having forcefully called this mass discrepancy of professional and public behavior to the forefront of our consciousness. Ceasing to name lesions that are most likely indolentomas by that fearsome word 'cancer' is the first step. Almost any patient who hears the word 'cancer' applied to their pathologic findings experiences their hair catching on fire." 

In an interview with National Public Radio, Esserman, a breast cancer surgeon, said: "Many of these precancerous lesions are not going to go on to become cancer. I don't think we should label it as cancer. I think we should call it a 'ductal lesion.' I think people would be much more willing to be calm about it."

Charlotte heart specialists work 'virtually' with Belize counterparts

Heart specialists from Carolinas HealthCare System have been to Belize many times to assist with surgeries and other medical care.

But on Tuesday, they didn't even have to leave Charlotte to help their colleagues in Central America.

From a conference room at Carolinas Medical Center, Dr. Francis Robicsek, vice president of Carolinas HealthCare's International Medical Outreach Program, launched a "virtual communication portal" with the Karl Heusner Memorial Hospital in Belize City.

The portal will enable cardiologists in Belize to consult with cardiologists from Sanger Heart & Vascular Institute in real-time on complex cardiac cases. 

At a demonstration Tuesday, Robicsek, Dr. Paul G. Colavita, Sanger president, and Dr. Geoffrey Rose, Sanger vice president, spoke with cardiologists in Belize through the portal.

It was the second portal of its kind launched by Carolinas HealthCare System in Central America. The first 

was launched in February 2012 with the Guatemalan Institute of Cardiology and Cardiac Surgery.

Since 2011, cardiology and surgical teams from Sanger have traveled to Belize every month to assist with cardiac catheterizations, open heart surgeries and stents. To date, more than 100 catheterizations and nearly 15 open heart surgeries have been performed on Belizean patients.

Dr. Paul Colavita, left, and Dr. Francis Robicsek demonstrated the virtual portal with Belize City physicians Tuesday at Carolinas Medical Center.

 Dr. Geoffrey Rose addresses health care providers and administrators at Carolinas Medical Center in person as medical personnel and administrators from Belize (visible on the screen) listen and interact through the "virtual portal." 

Affordable Care Act: Figuring out who's eligible for subsidies

With about a month left before enrollment begins in the new health insurance exchanges, the Kaiser Family Foundation has provided details that can help individuals determine what plans they might want to purchase and how much they might receive in federal subsidies.

Enrollment starts Oct. 1, and until then, consumers probably won't have enough information to make their choices. But don't worry. Enrollment lasts until March 30, 2014. That's six months to figure everything out.

People can begin to get familiar with the types of insurance plans that will be available. They're called bronze, silver, gold and platinum, with bronze plans having the lowest premiums and the most cost-sharing (through deductibles and copays) and platinum plans having the highest premium with the least cost-sharing.

Most people will not pay the "sticker prices" for health insurance premiums because they'll qualify for subsidies, Kaiser officials said.

Federal subsidies are available for individuals and families whose incomes are between 100 percent and 400 percent of the federal poverty level. An individual at 100 percent of the FPL would earn $11,490 a year, a family of four would earn $23,550.  An individual at 400 percent of the poverty level would earn $45,960, a family of four would earn $94,200.

I've included below the Subsidy Calculator provided by the Kaiser foundation.
If you need more information, click here to link to the Kaiser foundation website.

Or click here for McClatchy coverage of the Affordable Care Act.

Better hospital price transparency coming next year

A North Carolina law requiring hospitals to provide public pricing on 140 medical procedures and services went into effect Wednesday, when it was signed by Gov. Pat McCrory.

But don't expect more transparency for a few more months.

Spokespersons for Carolinas HealthCare System and Novant Health, which operate eight hospitals in Mecklenburg County, said the actual posting of charges isn't required until March 31 for inpatient procedures and June 30 for outpatient procedures.

Both systems say they'll be submitting data to the North Carolina Department of Health and Human Services in advance of those dates. The state will publish the information on its DHHS website.

The new law also prevents hospitals, in certain situations, from putting a lien on a patient's residence to collect on unpaid medical bills. That provision takes effect Oct. 1. Hospitals will also be required to submit their charity care policies to DHHS for publication on the state website.

"Transparency is a good first step to fixing things, " said Sen. Bob Rucho, a Matthews Republican who led the push for the changes.

The law, which received bipartisan support in the legislature, came about after a series of articles in the Observer and The News and Observer of Raleigh last year explored how the growing market power of hospitals has driven up prices.

The stories revealed soaring profits at nonprofit hospitals, seven-figure executive salaries, and efforts by hospitals to sue uninsured patients delinquent on their bills or to turn over the accounts to collection agencies.

"For too long, North Carolina patients have been in the dark on what they can expect to pay for common medical procedures when they are admitted to a hospital," McCrory said in a news release. "This new law gives patients and their doctors pricing information so they can make an informed financial decision with regard to their health care."

Earlier this year, the federal government published a database on the cost of 100 common hospital procedures and services across the country. The newspapers' review of hospital pricing in North Carolina found that, in three-fourths of the services examined, the highest price was triple or more compared to the lowest price for the same procedure. For example, the price for implanting a pacemaker in North Carolina ranged from $22,000 to $75,000, according to the federal database.

Restaurant-goers need calorie information sooner, study says

I have appreciated the growing practice of listing calorie information on restaurant menus and vending machines. But Duke University researchers say it's too little too late.

In a study published today, they suggest a better approach: Improve calorie listings on websites and mobile apps so customers can prepare to order healthy items before they arrive.

"If consumers wait until they enter restaurants to make purchasing decisions, it might be too late," said lead author Gary Bennett, an associate professor of psychology and neuroscience, global health at Duke. 

"Particularly for those who are watching their waistlines, it’s important to make plans before stepping through the restaurant doors."

The Food and Drug Administration is working out the final rules for menu calorie labeling as part of the Affordable Care Act.

The Duke study, published on the website of the journal PLOS ONE, assessed the top 100 U.S. chain restaurants’ websites for the availability of and ease of access to calorie information. 

The study, funded by the Duke Obesity Prevention Program, found that only 46.3 percent of the restaurants surveyed had a separate online section identifying healthy eating options. Increasing this feature on restaurant websites could help diners make better choices, researchers said.

Similar research by Gavan Fitzsimons at Duke's Fuqua School of Business has found that including a healthy option on an in-store menu did not translate into healthier eating choices. On the contrary, Fitzsimons found that just seeing the healthier item on an in-store menu tended to make people more likely to eat less-healthy food. (What does that say about human behavior?)

Another Duke study done in King County, Washington, found that adding nutrition facts to menus at one fast-food chain had no effect on consumer behavior in its first year.

Health insurance premiums show 'moderate' growth

Health premiums increased by a "moderate" increase 4 percent in 2013, according to this year's Employer Health Benefits Survey released today by the Kaiser Family Foundation/Health Research & Educational Trust.

Drew Altman, President and CEO of the Kaiser foundation, said the country has been seeing moderate premium increases in health insurance in recent years, especially compared to the years of "startling double-digit increases."

But he said "you can't blame the public" for having a sense that premiums are going up faster than usual because, over time, what people are paying for health care "has so significantly eclipsed the increase in their wages and inflation."

The survey looks backward, not forward, and Altman didn't make a prediction for the future. But he added that people who want to blame Obamacare for "big premium increases" will have a harder time because "there aren’t any big premium increases" this year.

For another view about the slowdown in healthcare spending, Altman referred to an article by Gail Wilensky in the May 31 issue of the Journal of the American Medical Association.

George W. Bush's heart surgery prompts debate about stents

Americans have become familiar with the idea of using stents to open blocked arteries, so when former President George W. Bush underwent stent surgery recently, most people probably viewed the decision as routine.

But there is -- and should be -- a national debate about when to use this expensive therapy.

Here's an excerpt from the blog Health Beat by Maggie Mahar, who quoted Bloomberg News: 

“The discussions have been ongoing since 2007, when the trial known as Courage first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with chest pain. The results were confirmed two years later in a second large trial.

“The debate has centered on both the cost of stenting, which can run as high as $50,000 at some hospitals, and its side effects, which can include excess bleeding, blood clots and, rarely, death. Opponents say the overuse of procedures like stenting for unproven benefit has helped keep U.S. medical care on pace to surpass $3.1 trillion next year, according to the U.S. Centers for Medicare and Medicaid Services.

“ 'This is really American medicine at its worst,' said Steven Nissen, head of cardiology at the Cleveland Clinic in Ohio  . . .  ‘It’s one of the reasons we spend so much on health care and we don’t get a lot for it. In this circumstance, the stent doesn’t prolong life, it doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better’ . . .

“ 'Stents are lifesaving when patients are in the midst of a heart attack,’ added Chet Rihal, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota. ‘...They allow immediate and sustained blood flow that help a patient recover. For those who aren’t suffering a heart attack, the benefits are less clear   . . . While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks.’  A review of eight studies published last year in JAMA (Journal of the American Medical Association) Internal Medicine also found no differences."