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Tuesday, May 3, 2016

Lung Cancer Screening Saves Lives

By Sid Roberts, MD
Lufkin Radiation Oncologist

This article originally appeared on Dr. Roberts' blog.

For more than 50 years now, we have known the dangers of smoking. That smoking causes heart disease, emphysema, and lung and other cancers is not in dispute. For fifty years, we did not have an effective screening tool for lung cancer.

Now we do.

Medical imaging has improved so much that we are now able to do computerized tomography (CT) scans with significantly lower dose to the patient and at a low enough cost to warrant widespread use as a screening tool. Not everyone needs a scan, of course. But smokers who are at high risk of developing lung cancer now have an option for screening, much like mammography for early detection of breast cancer.

In 2011, the results of the National Lung Screening Trial (NLST) were published in the New England Journal of Medicine, arguably the foremost medical journal in the world. This trial screened current or former heavy smokers aged 55 to 74 with low-dose CT scanning of the chest and compared it to standard chest x-ray. The NLST primary trial results show 20 percent fewer lung cancer deaths among trial participants screened with CT compared to those who got screened with chest x-rays. This is huge news, because we haven’t cured a lot of lung cancer over the last 50 years! Based on these results, the Centers for Medicare & Medicaid Services (CMS) decided in 2015 to start paying for the procedure on January 1, 2016.

According to the American Cancer Society, in 2016 an estimated 224,390 people in the U.S. (117,920 men and 106,470 women) will be diagnosed with, and 158,080 men and women will die of, cancer of the lung and bronchus, the leading single cancer killer in the U.S. If everyone who was eligible got screened, more than 30,000 deaths from lung cancer could be averted every year.

There are more than 94 million current and former smokers in the U.S. at high risk for lung cancer. In 2014, an estimated 18.1 percent, or 40 million U.S. adults, were current cigarette smokers. Unfortunately, smoking rates in East Texas are higher than state and national averages. That means a lot of East Texans are eligible to be screened.

Starting last fall, CHI St. Luke’s Health Memorial began offering low-dose CT lung cancer screening to eligible patients. Medicare covers ages 55-77 (commercial insurance 55-80, but Aetna 55-79). Even within those age ranges, an eligible patient must be a current smoker (or quit no more than 15 years) with at least a 30 pack-year history of smoking (for example, smoking 1 pack per day for 30 years, or 2 packs per day for 15 years). And, eligible patients must have no symptoms of lung cancer (such as coughing up blood or unexplained weight loss of more than 15 pounds in the last year). If lung cancer is suspected, a standard CT chest should be done.

Finally,  Medicare requires “shared decision making” on the risks and benefits of lung cancer screening, which means you must meet face to face with your primary care provider to get an order for screening.

Since we started screening at CHI St. Luke’s Health Memorial, more than 70 patients have been screened. Six abnormalities have been found (including an incidental kidney mass), and two lung cancers have been diagnosed. Those two cancer patients’ lives may have been saved by screening; only time will tell.

Of course, the best way to prevent lung cancer is by not smoking. Ever. Quit if you do smoke. And if you meet the criteria listed above, talk to your doctor about getting screened for lung cancer.

Dr. Sid Roberts is a radiation oncologist at the Arthur Temple, Sr. Regional Cancer Center in Lufkin. He is a contributing writer for the Lufkin Daily News and blogs at SRob61.blogspot.com

Thursday, April 21, 2016

Video: CDC's Immunization Baby Book

It's National Infant Immunization Week. The Centers for Disease Control and Prevention (CDC) created the following immunization baby book video, illustrating when a baby should receive his or her recommended vaccines.

For parents there's no greater joy than watching your child grow up happy and healthy. That's why most parents choose the safe, proven protection of vaccines. Flipping through this baby book, you can learn what vaccines babies need, when they're needed, and why it's so important to follow CDC's recommended immunization schedule. Immunization gives you the power to protect your baby from 14 serious childhood diseases by age 2. For more information about vaccines, visit http://www.cdc.gov/vaccines/parents.


Friday, April 15, 2016

We Can’t Afford to Take Vaccines for Granted

By Lisa Swanson, MD
Mesquite Pediatrician
Chair of TMA’s Council on Child and Adolescent Health

A mother in my office told me that a friend who is a lawyer is planning not to vaccinate his baby after he is born. He feels humans were born with a natural immune system, and we should stand back and let it do its job.  Although such a statement makes me sad, it also is a testament to how much we take for granted in the health of children. We expect children to be healthy and live into adulthood. We have forgotten the devastating illnesses of the past.

My father’s youngest sister died of diphtheria when she was 3 years old. I remember my aunt, who was in her 80s at the time, crying as she told me the story of watching her little sister cough and choke and eventually die. The pain of Helen’s loss never left her.

While I was in medical school, I had a friend at church who was spending his life in a wheelchair because of polio. A patient suffered permanent deafness in her ear after a long and frightening bout with meningitis. A friend of mine dealt with a pertussis (whooping cough) epidemic in residency in which several children died. I watched children with measles who would lie in a dark room and not move. During residency, I watched a child paralyzed for weeks to prevent him from dying of tetanus.

Even with the availability of vaccines, Texas has an increasing rate of pertussis, or whooping cough. The children cough to the point where they cannot breathe, and some die. We have had outbreaks of measles. For vaccines to be effective, more than 90 percent of the population needs to be vaccinated.

In answer to the father’s statement that we should let the natural human immune system do its job, all I can think is that it’s sad someone would be so determined to return to survival of the fittest. While it is true we would have many fewer humans on earth, and it might help global warming, who wants to return to the Middle Ages when widespread death from plague would kill large communities? Or even the early 1900s when children routinely died from a variety of illnesses including pneumonia, meningitis, and flu.

Vaccines are the single greatest scientific breakthrough of the 20th century to protect children. Vaccines keep them safe and allow them to grow to healthy adults. It is in a child’s best interest to be vaccinated; but because young children do not always make an adequate immune response to vaccines, adult family members also should get vaccinated for pertussis and flu to help provide even more protection for the kids.

The health and life of every child is important. Every child deserves to live a full life and a chance to succeed.

Thursday, April 7, 2016

Walking the Walk — A New Experience

By Ana Leech, MD
Houston Palliative Care and Hospice Physician
Medical Director Memorial Hermann Hospice IPU
Medical Director of Palliative Medicine Memorial Hermann Southwest

Editor's Note: This is the first part in a series.

As a hospice and palliative medicine doctor, I talk the talk every day. I sit down with very ill patients and their families. I review the medical facts, talk with the medical team and help them figure out what their values are, and empower them to proceed in the right path for them.

It is my turn to walk the walk.

As the doctor in the family, my mom filters most of my parents’ medical needs through me, so I was not surprised when she called me a few weeks ago to ask for a neurologist. She was sure Dad had had a stroke. She described difficulty finding words and completing his thoughts. Since I hadn’t seen him recently I thought nothing of it and gave her the number of a neurologist friend I trust to care for him right.

The appointment with the neurologist was on a Friday; I was busy at work and didn’t worry about it until Mom called to say that he put MY dad on medication for dementia! Dementia is doctor talk for slow, progressive brain failure that always leads to death while causing suffering for years to both the patients and the families caring for them.

I was now on the roller coaster that families find themselves in and didn’t know it. I guess at least I had an idea of what was coming, but not having any personal experience made this all new at the same time.

I managed to get a little more information that night, which helped allay my fears mainly because an MRI (a test that uses magnets and radio waves to produce images of the brain) was ordered, and I could keep my mind off the possibility of dementia if I just delayed any intrusive thoughts until the results of the MRI were back. That was until my sister googled what the medication was and got my mind going on how life would be for the next 10-12 years if Dad really had dementia.

Of course, as it always works, the MRI was inconclusive, but at least it ruled out dementia by showing a large defect — a mass. Somehow that was a relief for all of us. A contrast MRI (in which a chemical agent is injected into the patient to make abnormalities more visible in the MRI images) was suggested to have a better idea of what was happening.

And that’s when it became time to honor Dad’s wishes and let him call the shots. I ask families to do this every day. It is my turn.

He refused any further studies. No more blood work or radiology studies. Biopsies and treatment were completely out of the question! Although I was not surprised by this, the neurologist was. He pleaded I convince him, force him if needed, to get the contrast MRI. This would be completely against his wishes and against what I preach every day!

I decided to spend the day away from work with him, doing things he would enjoy. A day to be his one daughter who “gets him.” The one who knows the car exhibit at the museum was something he would really enjoy — and is willing to go to it. During that day I sort of tried to talk him into the test, but I didn’t push. I am walking the walk after all.

But as a physician I know, in reality, the contrast MRI is not really needed. Something that looks like a mass is in his brain. Swelling is causing pressure and making his brain not work right. This is obviously not benign (whether it is cancer or not). The relatively quick onset of symptoms makes this likely to be a short-lived process. Treatment options at this age would only serve to torture him and at best prolong the suffering a little.

Trying to be a daughter instead of a doctor is very hard. I can think of prescriptions he needs to ensure his comfort. It is keeping me up at night knowing he does not have them yet. I want to get him settled. I need to make sure all legal documents are in order. It needs to be done before the pressure thwarts his mental capacity to do it. We are on a time crunch.

Of course, he is in complete denial, which makes some things impossible — like final estate planning. Since neither of my parents has a will, my mom and I decided to proceed with wills for both of them, as if nothing is wrong.

One of the hardest things to do has been explaining to everyone that he is not getting “worked up,” meaning we are not pushing treatment. I have to stand his ground and explain every single time that he does not want treatment, that the risk of complications is too high for his comfort level, and that we are letting nature take over. I am in the perfect position to be his advocate because I understand both worlds. I really feel for families who don’t have someone like me built in. They get pushed and shoved every which way modern medicine wants. I am glad he has me, as hard as it is for me. I am here to ensure his will be done.

This idea that there is nothing to do is so erroneous. There is so much to do. We have to enjoy time with him, eat chocolate, share a cocktail or two, and look at cool cars. We have to ensure his comfort, and provide symptom management and emotional support. We have to watch out for Mom, who is losing her life partner of more than 50 years. Whoever said there was nothing to do clearly does not understand how complicated and important end-of-life care is.

I love doing what I do. I like to say I rescue people from the hospital and give them the care they deserve. I have always felt compassion and empathy in my work, but now I am strangely in both worlds. Now, telling people time is short has a new meaning; seeing a developing bed ulcer hurts a little more; talking with families who are in a sort of limbo is that much harder. I still love what I do, and I hope that my dad gets the care I strive to deliver, but the job is a little more painful now.

When it comes to the end of life, I was raised to be pragmatic and accept that it comes to all. I was always told that birth itself was a death sentence. This is not something unexpected, yet I just feel like crying. My eyes fill with tears at random times, and it is hard to hold back. I am already missing him. I am deep into what we call anticipatory grief. It is awful.

My dad is dying.

He is going to need hospice care. He is doing well enough for now, and although he meets Medicare criteria for hospice, he would not welcome a nurse visiting him every week at this point. We will wait until his health declines enough that my mom needs help, or until he accepts what is happening, whichever comes first.

Dr. Leech is a Houston palliative care and hospice physician. She is medical director at Memorial Hermann Hospice IPU and medical director of palliative medicine at Memorial Hermann Southwest.

Wednesday, April 6, 2016

Bias in Social Media: A Warning Against Crowdsourcing Your Medical Care





By Emily McCullar, MD
Austin Family Physician

Whether big questions or small, medically related or otherwise, social media users love to take their ponderings and perplexities to their friends to gather advice. Certainly, social media is a great place to poll opinions about the latest movie or book, and some might find asking friends for medical advice online easier than going to the doctor. Some might even feel that this collective problem-solving protects them if they believe physicians’ or health care providers’ financial motivations might preclude sound medical advice. But asking people outside the medical community for health advice carries its own set of risks.

It’s natural to assume family, friends, and Candy Crush competitors would offer medical advice purely out of the goodness of their hearts. But their own life experiences can color this advice and may not be in the patient’s best interest. For example, the patient asking about solving a high cholesterol problem with diet and exercise instead of pharmaceutical treatment might win encouragement from his Facebook friends. He may hear about someone’s terrible side effects while on a cholesterol-lowering medication. These comments will certainly lead him to believe that he is better off without medication, but is he really making a well-informed decision?

In asking friends if he should forgo this medication, the patient likely would not offer the full picture including his medical history. Readers of this man’s status update might assume his doctor is a bully who has never given him a chance to make some lifestyle changes. The 140 character-or-less blurb omits months or even years of ongoing dialogue between patient and physician. Perhaps during the patient’s prior three visits his doctor suggested diet and exercise (most physicians would), but the patient continued to gain weight, making medication the next most appropriate step. The patient is probably unlikely to share this with his online community.

Similarly, the patient’s friends might withhold their own unflattering, socially unacceptable, or simply poor medical experiences. For example, friends who suffered a stroke or heart attack after refusing medication or failing to make lifestyle changes might not admit that on social media. Likewise, the woman who questions taking antibiotics before her baby’s birth will not likely hear rebuke from someone who has lost a child to infection, as loss of a child is painful for everyone involved and typically kept private. Aside from those who turn to social media as their own personal tell-all live feed, friends online typically won’t discuss the risks of going against medical advice, because to share this information is often uncomfortable or socially inappropriate. Or some simply refuse to believe they’re wrong, despite evidence to the contrary.

On the other hand, members of the medical community are trained specialists well-versed in offering advice without bias. Evidence-based medicine is the gold standard for physicians when determining treatment options, and learning to operate within the limits of evidence-based medicine is a primary focus of medical training. Doctors are trained to distinguish appropriate medical studies from those containing bias. That’s part of our expertise on which patients rely. Most patients and friends do not benefit from that experience, so how could we expect their anecdotal “evidence” offered via social media to be accurate? Personally, I could not stand the possibility of harming my patients, either medically or emotionally, so evidence-based medicine has become my strength in offering well-supported treatment to patients.

When physicians suggest a treatment plan, there is usually a body of evidence that supports their advice. Years of education and personal concern for their patients (and possibly a touch of fear of litigation) have trained them to offer the best-supported and least-biased information they know. While friends on social media may offer opinions on medical matters, it is crucial when considering your own health to keep in mind the expertise, motivation, and bias of your source.

Dr. McCullar is a family medicine resident physician caring for patients in the Austin area. 

Tuesday, April 5, 2016

By Not Discussing Cost Issues, Doctors, Patients May Miss Chances To Lower Out-Of-Pocket Expenses

By Shefali Luthra
Kaiser Health News

Content provided by Kaiser Health News

Talking about money is never easy. But when doctors are reluctant to talk about medical costs, a patient’s health can be undermined. A study published in Monday’s Health Affairs explores the dynamics that can trigger that scenario.

Patients are increasingly responsible for shouldering more of their own health costs. In theory, that’s supposed to make them sharper consumers and empower them to trim unnecessary health spending. But previous work has shown it often leads them to skimp on both valuable preventive care and superfluous services alike.

Doctors could play a key role in instead helping patients find appropriate and affordable care by talking to them about their out-of-pocket costs. But, a range of physician behaviors currently stands in the way, according to the study.

“We need to prepare physicians to hold more productive conversations about health care expenses with their patients,” said Peter Ubel, the study’s main author and a physician and behavioral scientist at Duke University.

The researchers analyzed transcripts of almost 2,000 physician-patient conversations regarding breast cancer, rheumatoid arthritis and depression treatment. They identified instances in which patients suggested that the cost of care might be difficult to afford and assessed how doctors responded.

Overall, researchers noted two ways in which doctors dismissed patients’ financial woes. They either did not acknowledge the concerns patients expressed or only half-addressed them. For instance, if a patient commented on how expensive a drug was, the doctor might ignore the comment entirely or might suggest a temporary solution — like a free trial — without exploring long-term strategies to address the issue.

And, without such a long-term plan, patients may eventually stop taking the medication, or take it irregularly. That can harm their health, and even send them to the hospital.

The study doesn’t measure how often doctors dismissed patient concerns — because, the researchers wrote, they didn’t know how often those dismissals led to people actually foregoing needed treatments.

Still, Ubel said, it is clear doctors are not talking to patients about these expenses. He pointed to a separate analysis of those same conversations, which found that doctors discussed medical costs with patients about 30 percent of the time; and, in only about 40 percent of those discussions did doctors and patients brainstorm about ways to make medication more affordable.

“A majority of [physicians] — they don’t talk about costs,” he said. “When they do talk about it, they don’t talk about it productively.”

Why do physicians hesitate? For one thing, they aren’t used to discussing cost barriers, and many think it’s inappropriate to bring up money at all, Ubel said. When he lectures on the subject, he always encounters people who worry discussing finances will “contaminate the doctor-patient relationship.”

Plus, doctors haven’t been taught to listen for patients’ pocketbook concerns. If a patient comes in with heartburn and indigestion, a good internist will immediately start probing for signs of coronary disease, Ubel said. By contrast, physicians aren’t primed to pick up on cues that patients may face financial strains.

“If we had that on our list to be aware of, we’d pick up the cues. If we don’t, it’ll be right in front of our eyes, and we’ll miss it,” he added.

The idea of patients acting as consumers — weighing cost and shopping for the best health care deal — is still relatively new, the study notes. As it becomes more commonplace, patients may push doctors for more help in making cost-based decisions, Ubel said.

That said, navigating a patient’s financial circumstances and medical needs in the course of a 15-minute visit is tricky, said Jonathan Kolstad, an assistant professor of economic analysis and policy at the University of California, Berkeley. Kolstad wasn’t involved in the Health Affairs study but has researched how medical costs affect people’s decision-making.

“It’s not as though, ‘Oh, it’s just consumers can’t figure it out.’ Doctors don’t know,” he said. When it comes to figuring out what a drug will cost, “doctors are in the same boat.”

This article was produced by Kaiser Health News.

Tuesday, March 22, 2016

Why the Hepatitis B Vaccine Is a Must for People with Diabetes

By Janice Stachowiak, MD
Lubbock Internist
Member, TMA Be Wise ― ImmunizeSM Physician Advisory Panel

March 22 is American Diabetes Association Alert Day.

People living with diabetes are more susceptible to infection. That is why it is so important for them to get the flu vaccine every year. But there is another important vaccine that diabetics need to get also ― the Hepatitis B vaccine.

Hepatitis B is a contagious liver disease that results from infection with the Hepatitis B virus. Some infected people are able to fight the virus and clear the infection. For others, the infection will remain and develop into chronic Hepatitis B. Over time, chronic Hepatitis B can cause cirrhosis of the liver and lead to complications such as liver failure or liver cancer. 

People with Type I or Type II diabetes have higher rates of Hepatitis B than the general population. Why would this be? The Hepatitis B virus is usually spread when blood or other body fluids from an infected person enters the body of someone who is not infected. Hepatitis B can spread through the sharing of needles, razors, injection equipment, and through sexual contact. The Hepatitis B virus can also be spread from an infected mother to her baby. People with diabetes are at increased risk for Hepatitis B if they share glucometers, fingerstick devices, syringes, or insulin pens. The Hepatitis B virus can survive outside the body, and possibly on medical equipment, for at least a week and can still cause infection if it enters the body of someone who is not infected. Diabetics who need help monitoring their glucose and live in skilled nursing facilities can be at increased risk if proper procedures are not followed. That is why it is so important to be proactive and get vaccinated.

In 2011, the Centers for Disease Control (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommended that all diabetic adults under the age of 60 be vaccinated against Hepatitis B. The effectiveness of the Hepatitis B vaccine decreases with age. If you are over 60 and living with diabetes, talk with your doctor about possible vaccination against Hepatitis B. The decision on whether are not to vaccinate against Hepatitis B will depend on your risk of infection and your overall health status.

Due to the Hepatitis B infection being potential deadly and preventable with vaccination, the CDC and the ACIP recommended in 1999 that all children and adolescents be vaccinated against Hepatitis B. In a few decades, most adults with diabetes should already be vaccinated against the Hepatitis B virus. 

The Hepatitis B vaccine is a series of three shots given over six months. All three shots are needed for long term protection.

If you have diabetes and have not been vaccinated against Hepatitis B, talk with your doctor about vaccination.

Dr. Stachowiak, an internist from Lubbock, teaches at Texas Tech University Health Sciences Center in Lubbock. She is a member of TMA’s Be Wise – ImmunizeSM Physician Advisory Panel and is a member of the South Plains Immunization Network.
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