Category Archives: Treatment & Management

Is Newer and More Expensive Care Better?

Sarah Miller, RN and Laura Covarrubias

Is more medical care really better? What about all these new, expensive drugs and high-tech surgeries? Do they save lives or improve health?

If you answered yes to these questions, you are not alone, but you may not be correct. A study done by the American Institutes for Research on insured adults between ages 18 and 64, found that most thought that more care, newer medical technology, and more expensive care were better. In addition, the adults interviewed believed that all care met minimum quality standards, and they were skeptical of evidence-based medical guidelines.

A typical response was “I don’t see how extra care could be harmful to your health. Care would only benefit you.” Although this belief is widely held, it is not accurate.  For example, if a healthy 80-year old man or woman without cancer symptoms is screened for various types of cancer, any abnormal findings are likely to result in treatment that is unlikely to benefit them.  That is why the U.S. Preventive Services Task Force usually recommends against screening 80-year olds for these cancers, although they recommend diagnostic testing for patients of all ages if they have symptoms.

“You get what you pay for” is another popular opinion, with many people assuming that more expensive care is superior. However, care that is far less expensive is sometimes just as good or even better.  One example of this is robotic prostatectomy, a surgery for men with prostate cancer that is done by a robot operated by the surgeon. Many men want this type of surgery, which costs $2,600 more than a regular prostate surgery. Some studies have shown that men who have the robotic surgery have lower rates of complications after the surgery, but others have shown that there is no difference. Most researchers who have conducted studies on this agree that the robotic surgery has not yet been proven to be any better than regular prostate surgery.

Even if robotic surgery isn’t worse than the regular surgery, is it worth the extra $2600? Consider this: for every two insured men that choose to have regular rather than robotic surgery, the cost savings could more than pay for one uninsured man with prostate cancer to have this life-saving surgery.[5] This is important to consider in the United States, where many people are not able to afford their medical care.

A similar idea that many patients have is “if it’s newer, it’s better.” While it may seem like new treatments would be chosen because they are better, this is rarely true. For example, cetuximab (also called Erbitux) was introduced in 2008 as a new addition to treatment for lung cancer patients. Although the drug was called a breakthrough in treatment for lung cancer, the average patient taking the drug lived only 1.2 months longer than patients not taking the drug. And in the many months of taking the drug, 85% of patients experienced skin toxicity, which often caused great discomfort (Fojo & Grady).  And despite the small possible advantages of the drug, it cost $80,000 for just a few months of treatment, resulting in huge medical bills that many families could not afford.  Avastin for Stage 4 breast cancer is an even more dramatic example.  Avastin is used for many cancers, but after several years, it became clear that on average, the breast cancer patients taking it were not living any longer and were more likely to have a stroke or other very serious and debilitating reaction to the drug that could make their last months much more painful physically and psychologically.

Cereal companies regularly add “New” in big letters on cereal boxes, because that sells more products (even if what is new might be a new toy inside).  Patients should be more cautious.  While some patients may want to take the chance that a new drug might be better, but many would rather know what the risks are before trying a new medication that could be worse than the tried and true treatments.

Evidence-Based Guidelines

Medical guidelines are usually established by a group that is considered expert in the subject of the guidelines. Medical guidelines are usually based on evidence from scientific research and are written according to the agreement a group of experts comes to about what the research tells them is the best for patients.

Unfortunately, research indicates that many adults are skeptical about guidelines.  Many seemed to think that asking providers to use guidelines did not allow them to make decisions based on their own expertise and that they could be used to ration care so that people did not “take” too much. One participant said that medical guidelines are “taking your choice away and putting it in someone else’s hands.”

Contrary to the mistaken belief that providers were restricted to actions dictated by the guidelines, in reality, guidelines are meant to guide providers by making suggestions based on the best evidence. Providers are still able to make the final recommendation to patients based on their professional expertise.

Is a doctor’s individual experience more valuable than guidelines?  That’s hard to say, but usually it would not be.  Guidelines are based on evidence from medical research comparing large groups of people who have had different types of treatment. Therefore, guidelines based on science will, on average, provide the best care for most people.  However, a physician with impressive expertise may be able to predict which patients are more likely to benefit from other types of treatment.

For example, for years, it was recommended that women between 40 and 69 years of age have a mammogram every year to screen for breast cancer. In 2007, however, the American College of Physicians changed their guidelines to leave it up to physicians to decide whether women between 40-50 needed annual mammograms.  In 2009, the US. Preventive Services Task Force wrote new guidelines, based on research evidence from thousands of women. The new guidelines recommended that women age 40-49 should not have regular mammograms to screen for breast cancer unless they had an especially high risk of breast cancer, and that women age 50-75 should have screening mammograms every two years – extending the age to older women but cutting the frequency from annually to every other year.

Many people challenged the new guidelines believing they could substantially delay the detection of cancer, especially for women under 50.  Isn’t it always better to have a chance to detect cancer earlier?

The answer is yes and no. Although mammograms save the lives of many women (including those in their 40’s), they also expose women to harmful radiation that can actually cause cancer over the course of women’s lifetimes. The researchers considered other forms of harm as well, such as the emotional trauma of a “false positive” results that result in stressful and expensive biopsies.  They concluded that the potential for harm outweighed the potential benefits of mammograms for the average women under age 50 and over 75, as did annual rather than biyearly mammograms for women age 50-75.

Many people did not agree with the U.S. Preventive Services Task Force’s interpretation of the evidence, however.  It is partly a matter of interpretation.  The U.S. Preventive Services Task Force was advising average women, and some cancer advocates believe that it is too difficult to predict whether a person is at high risk or not.  As a result, groups such as the American Cancer Society prefer to err on the side of over-treatment and radiation exposures, rather than on the side of potential under-treatment and reducing radiation exposure.

Health care providers are able to judge the two sets of guidelines and decide what to recommend for specific patients. For example, a woman in her 30’s who has many family members with breast cancer, including some at a young age, may be advised to have digital mammograms every other year in their 30’s (because they are more accurate than traditional mammograms and use less radiation) and annually after that.

“All care meets minimum quality standards” is another common belief.  Most could imagine providers making an occasional mistake, but few thought that there were any providers who consistently delivered a quality of care that did not meet basic standards.[1] Unfortunately, research shows that health care varies from doctor to doctor, and many do not meet minimum quality standards. The quality of care that doctors provide varies by the type of clinic where they work (publicly or privately funded, for instance), the communication skills of the doctor, and even how much sleep the doctor has been getting (Manusukhani; Kenny; Philipson).

What Can We Learn From This?

This study gives some insight into why we spend so much on health care and why efforts to improve medical care are often opposed as “rationing” or “death panels.” Unfortunately, most patients want the newest and most expensive care, and don’t understand that it may not be as safe or as effective as older, less expensive treatments.

In the United States, we spend more per person on health care than any other country, and yet our citizens are not as healthy as those in Japan, France, and Cuba, countries that spend far less per person on health care.

In addition to wasting money on treatments that are no better, and are sometimes inferior, our wasteful spending also means that we have less money for other essential services, such as education, housing, and national security.4

Of course, there is a lot of very expensive medical care that is medically necessary and could save a person’s life, such as trauma care in an emergency room for someone who has been in a serious car accident. But, there are also popular treatments that are expensive and not necessary, like a woman having labor induced for convenience when it would be safer and less expensive to have a natural birth. The key is to eliminate the unnecessary care so that we can continue to afford the necessary, beneficial care.

When it is not clear whether more expensive care actually helps or is just a waste of money, medical research can point us in the right direction. That’s why it is a good strategy to require “comparative effectiveness research” to determine whether, for example, robotic prostate surgery is better than regular surgery, or just needlessly more expensive.  It is often not obvious which treatments are the best, and sometimes they are the most expensive treatments but other times they may be the least expensive treatments or no treatment at all.

Doctors and patients can be part of improving medical care, by asking whether research conclusively shows which treatment is safer and which is most effective, instead of wrongly assuming that guidelines are aimed at saving money, not improving care.

References:

  1. Carman, KL; Maurer, M; Mathews, J; Dardess, P; McGee, J; Evers, M; & Marlo, KO, Evidence that consumers are skeptical about evidence-based health care, Health Affairs, 7 1400-6, 2010.
  2. Centers for disease control and prevention. Births: Final data for 2006, National Vital Statistics Reports.
  3. Caughney, AB; Sundaram, V; Kaimal, AJ; Cheng, YW; Geinger, A; Little, SE; Lee, JF; et.al. Maternal and Neonatal Outcomes of induction of labor. Evid Rep Technol Assess. 176 pp.1-257, 2009.
  4. Bodner-Adler, B; Bodner, K; Patiesky, N; Klimberger, O; Chalubinski, K; Mayerhofer, K; & Husslein, P; Influence of labor induction on obstetric outcomes in patients with prolonged pregnancy: A comparison between elective labor induction and spontaneous onset of labor beyond term. The Middle European Journal of Medicine. 117(7-8) pp. 287-92, 2005.
  5. Bolenz, C; Gupta, A; Hotze, T; Ho, R; Cadeddu, JA; Roehrborn, C; & Lotan, Y; Cost Comparison of Laproscopic, Robotic, and Open Radical Prostatectomy for Prostate Cancer, European Urology, 57 pp. 453-8, 2010.
  6. Lowrance, WT; Elkin, EB; Jacks, LM; Yee, DS; Jang, TL; Laudone, VP; Guillanneau, BD, Scardino, PT; & Eastham, JA, Comparative effectiveness of prostate cancer treatments: A population-based analysis of postoperative outcomes, The Journal of Urology, 183, 1366-72, 2010.
  7. Weizer, AZ; Strope, S; and Wood, DP, Margin control in laproscopic robotic prostatectomy: What are the REAL outcomes? Urologic Oncology: Seminars and Original Investigations, 28 pp.201-14, 2010.
  8. Barocas, DA; Salem, S; Kordan , Y; Herrell, SD; Chang, SS; Clark, PE; Davis, R; Baumgartner, R; Phillips, S; Cookson, MS; & Smith, JA, Robotic assisted laproscopic prostatectomy for clinically localized prostate cancer: Comparison of short-term biochemical recurrence-free survival, The Journal of Urology, 183, 990-6, 2010.
  9. Murphy, DC; Bjartell, A; Ficarra, V; Graefen, M; Haese, A; Montironi, R; Montorsi, F; Moul, JW; Novara, G; Sauter, G; Sulser, T; & van der Poel, H, Downsides of robot-assisted laproscopic prostatectomy: Limitations and complications. 57 pp. 735-46, 2009.
  10. Coelho, RF; Chauhan, S; Palmer, KJ; Rocco, B; Patel, MB; & Patel, VR, Robotic-assisted radical prostatectomy: A review of outcomes, British Journal of Urology International, 104, 1428-35, 2009.
  11. US Preventive Services Task Force, Screening for breast cancer: Recommendation statement 2009. Retrieved from: http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htm  on July 20, 2010.
  12. American Cancer Society, American Cancer Society Guidelines for the Early Detection of Cancer: Breast Cancer, 2010, Retrieved From: http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer  on July 20, 2010.
  13. Smith, S; Newhouse, JP; & Freeland, MS; Income, insurance and technology: Why does health spending outpace economic growth? Health Affairs, 28(5) pp. 1276-84, 2009.
  14. Aaron, HJ and Ginsburg, PB; Is health spending excessive? If so, what can we do about it? Health Affairs

Lung Cancer and African Americans

Sarah Miller, RN, Cancer Prevention and Treatment Fund

For years, doctors and medical researchers have been puzzled by the fact that African-Americans are more likely to die from lung cancer than people of any other race or ethnicity, although they are not more likely to smoke. How could this be? Is it because they don’t get diagnosed and treated in time, is it genetic, or is there something else going on? Research indicates that a combination of factors may be responsible for the unequal rates of death from lung cancer.

The Problem

African-Americans are disproportionately affected by lung cancer. The percentage of African-American men diagnosed with lung cancer each year is at least 30% higher than among white men, even though they have similar rates of smoking as white men. In fact, African-American men tend to smoke fewer cigarettes per day than white male smokers. While African-American women are less likely to smoke than white women, they are about as likely to develop lung cancer and die from lung cancer as white women. African-Americans also tend to be diagnosed with lung cancer at a younger age. Research has examined many possible explanations for these differences.

Is it Genetic?

Scientists have recently identified several genes that are linked to lung cancer. People who have these genes and smoke are more likely to develop lung cancer than other smokers. They have also found genes that cause a person to metabolize nicotine differently, which could be a factor in whether a person develops lung cancer.6 Some of these genes have been found to be more common in people with African ancestry. This suggests that genetics may have a role in the higher rates of lung cancer among African-Americans.

Genetics are only a part of the equation, though. There are many other factors that contribute to differences in lung cancer rates and in death from lung cancer.

Does the Type of Cigarettes Matter?

Tobacco companies have a long history of targeting the African-American community with advertisements for menthol cigarettes. As a result, about 80% of African-American smokers smoke menthol cigarettes, compared with only 20% of white American smokers.

Many researchers have tried to find a link between lung cancer and menthol cigarettes. Some have theorized that the “cooling” effect of menthol cigarettes allows menthol smokers to inhale the smoke more deeply, which could cause more damage to their lungs. Others have speculated that menthol cigarettes might be more addictive than regular cigarettes.

While studies have shown that smokers of menthol cigarettes may have a more difficult time quitting, and are more likely to smoke their first cigarette sooner after waking in the morning than people who smoke regular cigarettes, researchers have not been able to find any chemical properties of menthol cigarettes that make them more addictive.

Smokers of menthol cigarettes do not, on average, smoke any more cigarettes in their lifetime than regular cigarette smokers, and research so far has failed to show that menthol cigarettes cause more cases of cancer than other kinds of cigarettes.

The one obvious problem with menthol cigarettes is that the menthol makes cigarette smoke less harsh for first-time smokers. Because, of this, many young teens smoke them. In fact, while smoking is declining among adults and adolescents, menthol cigarettes are becoming increasingly popular among both adults and kids ages 12-17. Since we know that people who begin smoking at younger ages are more likely to become regular smokers, it is troubling that there is a product available that helps teens to start smoking. Although African-American teens start smoking later than white teens, they disproportionately smoke menthol cigarettes.

Does the Environment Affect Lung Cancer Disparities?

Industries that produce heavier air pollution (for example, factories, oil refineries, and chemical plants) are often located in African-American communities. Exposure to pollution from working in or living near these industries can increase a person’s risk for lung cancer.,

A person who smokes and is exposed to air pollution is at higher risk for lung cancer than a smoker who is not exposed to air pollution. People who are exposed to air pollution on the job are at especially high risk. The fact that these polluting industries are frequently located in African American communities and employ members of that community may also help to explain why African-Americans are disproportionately affected by lung cancer.

Is it Because of Differences in Treatment?

While differences in diagnosis and treatment don’t explain why more African-Americans develop lung cancer, it may help to explain the higher death rate from lung cancer among blacks.

One study of all the lung cancer patients in the Florida Cancer Registry found that the survival time for African-American patients diagnosed for lung cancer was shorter than that of white patients. The researchers also found that the entire difference in survival time between African-Americans and whites could be attributed to the fact that white patients tended to get more timely and appropriate treatment.

They concluded that if African-American patients could begin treatment as early as white patients, and were provided the best treatment for their condition, then their survival time would catch up with that of white patients.

Another study found that many patients with a certain type of lung cancer, for which surgical removal of part of the lung offers the best chance for a cure, did not get the proper surgery. Shockingly, only 62% of all patients who would have a good chance of the surgery helping them had the surgery. When the researchers separated the results out by race, 66% of white patients who were appropriate candidates had the surgery while only 55% of African-American patients who were appropriate candidates had the surgery. While this is bad news for all patients with this type of lung cancer, it is worse news for African-Americans since they were substantially less likely than white patients to get the surgery.

Why Don’t African-American Patients Receive the Proper Treatment?

One reason that African American patients are less likely to receive the proper treatment than white Americans may be that they are less likely to have health insurance. While about 13% of white American adults under the age of 65 are uninsured, 21% of African American adults in the same age group are without health insurance. Uninsured patients may decide against treatment because they can’t afford it, or may have a difficult time finding a hospital that is willing to provide the treatment to uninsured patients.

Another reason that African American patients do not always receive the most appropriate care is that there seem to be communication problems between providers and patients.

Studies have found that the type of communication a patient has with a doctor or health care provider has an impact on his or her decision-making about treatments. In the long-term, this has a huge impact on the state of a person’s health.

Health care providers are increasingly pressured to fit more patient visits into shorter time periods. Because of this, providers have less time to spend getting to know each patient. In this type of situation, people tend to make snap judgments.

Providers make a judgment based on their first impression of a person (what they think of that person after glancing at his or her chart and based on personal appearance). This judgment influences the provider’s judgment about what medical information the patient wants or doesn’t want, what type of treatment the patient is likely to find acceptable, and how reliable the person will be with his or her follow-up care.

Patients, too, know that they have only a short time for an appointment. They also may judge a provider based on his or her appearance and make assumptions. They may assume that the provider is very knowledgeable and that they should just do what the provider says. Patients may also assume, based on a snap judgment, that the provider will not respond well to being asked questions, that the provider does not care about the patient, or that the provider is not going to be helpful.

Research has shown that when the provider is of a different race or culture than the patient, these breakdowns in communication are more severe and have more negative results in terms of the quality of care a patient receives.

What is Being Done to Reduce Disparities in Lung Cancer Survival?

While healthcare providers and lawmakers recognize that this is a serious problem, they also recognize that there is no quick fix.

One step that is being taken by medical schools is to try and attract more African-American students. Currently, African-Americans are under-represented in the medical profession. The assumption is that African-American physicians be able to communicate more effectively with African-American patients, and that they will be able to educate their colleagues to do so as well.

Many people are also trying to limit advertising of menthol cigarettes, especially ads that target African-American teens.

Some public health advocates are urging the FDA to ban menthol in cigarettes. Other flavored cigarettes (“bidis”) have already been banned on the principle that they attract teens to smoking and make cigarettes more tolerable. Since we know that menthol also makes smoking more desirable for teens, and since it is a flavoring for cigarettes, it makes sense that it should be banned along with the other flavors. Banning menthol cigarettes would likely reduce the number of African-American teens that smoke, and might help reduce lung cancer deaths among African-American men and women.

References:

Centers for Disease Control and Prevention; Summary Health Statistics for US adults: National Health Interview Survey, December 2008; Vital and Health Statistics, 10 (242), 2009.

Stellman, SD; Chen, Y; Mucsat, JE; Djordjevic, MV; Richie, JP; Lazarus, P; Thompson, S; et.al. Lung Cancer Risk in White and Black Americans.  Annals of Epidemiology. 2003. 13(4). Pp.294-302.

National Cancer Institute; SEER stat fact sheets: Lung and Bronchus. Surveillance Epidemiology and End Results. 2010. Retrieved from: http://seer.cancer.gov/statfacts/html/lungb.html#incidence-mortality

American Lung Association; Too May Cases, Too Many Deaths: Lung Cancer in African-Americans, 2010. Retrieved from http://www.lungusa.org/assets/documents/publications/lung-disease-data/ala-lung-cancer-in-african.pdf  on August 10, 2010.

Hansen HM, Xiao Y, Rice T, Bracci PM, Wrensch MR, Sison JD, Chang JS, et. al; Fine mapping of chromosome 15q25.1 lung cancer susceptibility in African-Americans. Human Molecular Genetics.2010 (Epub ahead of print)

Amos CI, Gorlov IP, Dong Q, Wu X, Zhang H, Lu EY, Scheet P, Greisinger AJ, Mills GB, Spitz MR. Nicotinic acetylcholine receptor region on chromosome 15q25 and lung cancer risk among African-Americans: a case-control study. J Natl Cancer Inst. 2010.102(15):1199-205.

Yerger, VB; Przewoznik, J; & Malone. RE; Racialized Geography, corporate activity, and health disparities: Tobacco industry targeting of inner cities. J Health Care Poor Underserved. 2007;18(4 Suppl):10-38.

Okuyemi KS; Ebersole-Robinson M; Nazir N; & Ahluwalia JS; African-American menthol and nonmenthol smokers: differences in smoking and cessation experiences. J Natl Med Assoc. 2004;96(9):1208-11.

9Muscat, JE; Chen, G; Knipe, A; Stellman, SD; Lazarus, P; & Richie, JP Jr. Effects of menthol on tobacco smoke exposure, nicotine dependence, and NNAL glucuronidation; Cancer Epidemiol Biomarkers Prev. 2009;18(1):35-41

10 Gandhi KK, Foulds J, Steinberg MB, Lu SE, Williams JM; Lower quit rates among African-American and Latino menthol cigarette smokers at a tobacco treatment clinic. Int J Clin Pract. 2009;63(3):360-7.

11 Murray RP; Connett JE; Skeans MA; & Tashkin DP; Menthol cigarettes and health risks in Lung Health Study data. Nicotine Tob Res. 2007;9(1):101-7.

12 Carpenter CL, Jarvik ME, Morgenstern H, McCarthy WJ, London SJ; Ann Epidemiol. Mentholated cigarette smoking and lung-cancer risk. Annals of Epidemiology. 1999;9(2):114-20.

13 Brooks, DR; Palmer, JR; Strom, BL; & Rosenberg, L; Menthol cigarettes and risk of lung cancer; American Journal of Epidemiology, 2003; 158(7), pp. 609-16.

Carballo R. (Epidemiology Branch Chief, CDC’s Office on Smoking and Health). Use of  Menthol Cigarettes by Demographic Group. Power Point delivered at the March 30-31 meeting of the Tobacco Products Scientific Advisory Committee Meeting, FDA. http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/ucm207149.htm

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Division; Results from the 2008 National Survey in Drug Use and Health: National Findings, 2008. Retrieved from: http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf   on August 24, 2010.

Elliot, MR; Wang, Y; Lowe, RA; & Kleindorfer, PR; Environmental Justice: Frequency and Severity of U.S. Chemical Industry Accidents and Socioeconomic Status of Surrounding Communities, J Epidemiol Community Health 2004;58:24-30.

Brenner DR, Hung RJ, Tsao MS, Shepherd FA, Johnston MR, Narod S, Rubenstein W, & McLaughlin JR; Lung Cancer in Never-Smokers: A Population-Based, Case-Control Study of Epidemiologic Risk Factors; BMC Cancer. 2010,14;10:285

Yang, RY; Cheung, MC; Byrne, MM; Huang, Y; Nguyen, D; Lally, BE; & Koniaris, LG; Do racial or socioeconomic disparities exist in lung cancer treatment? Cancer. 2010; 116(10) pp. 2437-47.

Cykert, S; Dilworth-Anderson, P; Monroe, MH; Walker, P; McGuire, FR; Corbie, Smith, G; Edwards, LJ; & Bunton, AJ; Factors associated with decision to undergo surgery among patients with newly-diagnosed, early-stage lung cancer; JAMA; 303(23) pp. 2368-76.

Kaiser Family Foundation; The Uninsured: A Primer, 2009. Retrieved from http://www.kff.org/uninsured/upload/7451-05_Data_Tables.pdf on August 30, 2010.

Smedley, BD; Stith, AY; & Nelson, AR; Assessing types of racial and ethnic disparities in care: The clinical encounter. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. pp. 29-79, 2003. National Academies Press, Washington, DC.

Gladwell, M; Blink: The Power of Thinking Without Thinking, 2005,

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