August 2008 Archives
As a physician, one of the obstacles that I struggle with each day is patients insurance or lack of insurance, or under insurance. My practice is one of a few practices in my area that accepts Medicaid. When I see a patient with Medicaid who needs a biopsy or surgical intervention, a lot of times it is a long, complex, difficult procedure to find physician who will see this patient and take care of them. It has always been a point of pride, in my practice, that we continue to accept Medicaid and we work desperately hard to take care of any patient that walks in the door, however, it is becoming increasingly difficult for practices like mine or all physician practices to continue to provide services to Medicaid patients. The amount of reimbursement that we receive from the work that we do with these patients doesn’t even come close to covering our costs associated with giving the high level care that we strive to give every patient.
Increasingly we are also seeing patients who are under insured with health care policies which are basically skeletons of what a patient needs, leaving the patient exposed to huge deductibles, and huge out-of-pocket costs & making care almost unaffordable. At times, unfortunately, I have had to modify my treatment course not based on what I thought was best for the patient, but what we were able to get covered and what the patient could ultimately afford.
I bring this up because we are now all watching the political conventions. There has been a great deal of talk about universal healthcare and healthcare as a fundamental right of every person in the United States. This notion of universal healthcare has been something I have struggled with my whole career, I have been desperate to try to take care of my patients the best possible way with the best possible medicines, and yet I have seen firsthand the absolutely, terrible management and terrible results that we have with all our government run health initiatives. The idea that our present day healthcare system will be replaced with something similar to Medicaid or Medicare with its bureaucracy, inefficiencies and sometimes, asinine coverage judgments scare me to death. This fear is counter balanced by the compassion, the need in my heart to care for every patient the same way without worrying about costs and money. I know that the current presidential race will likely affect healthcare in America for years to come. I pray everyday we get it right.
In May of this year, President Bush signed a bill into law that really didn’t receive much in the way of headlines or fanfare. This was the so called GINA law, which is a law that finally makes it illegal for employers or health insurance companies to discriminate against patients based on their genetic information. This is an incredibly important piece of legislation and I feel is long overdue in this country. Genetic testing is becoming much more frequent and much more widely done. More & more patients are having to deal with the idea that an underlying genetic abnormality is a possible root cause of their cancer or other disease. They also have to deal with the idea that these abnormal genes can be passed on to their children. The most well-documented and well-developed area is in the realm is in breast cancer. The BRCA-1 & 2 genes have been known and identified for at least the last decade and it is becoming more & more common for patients to be tested for these genes. Being positive for these genes has significant ramifications for patients and their offspring’s both in terms of management of their breast cancer and their increased risk for other types of cancer, such as ovarian cancer.
Breast cancer isn’t the only area that genetic abnormalities have been found; patients and families with high incidence of colon cancer are tested. There are also genes that increase the risk of melanoma. I suspect that over the next 5 to 10 years multiple new genes will be identified that provide information on a patient’s risk of developing certain types of cancers. This is an important fundamental shift in the way that we look at cancer. If we can truly identify patients that are at a significantly higher risk, we can then consider increased surveillance, prevention and possibly reduce the overall incidence of cancer. At the same time, it is scary for patients to have an abnormal gene found & identified in themselves and in their children. Hopefully the passing of the GINA law will relieve some of the patients’ anxiety. I believe that congress and the president got this one right.
When a patient is first diagnosed with cancer, one of the more difficult aspects of an oncologist’s job is determining which patients might benefit from chemotherapy. No place is this more keenly felt than in breast cancer patients. Each year, hundreds of thousands of women are diagnosed with breast cancer. Many of them receive chemotherapy based on a perceived risk of the disease returning. In the past, we have used critical characteristics, and information from the path report to determine whether a patient would be considered at high enough risk to benefit from chemotherapy. This is not always accurate and some women receive little or no benefit from chemotherapy. This, however, is changing with new tests that allow us to better characterize a woman’s breast cancer and help determine whether she would be a patient that would benefit significantly from chemotherapy. One such test is the Oncotype DX test that has been developed by Genomic Health. This test uses a series of genes that have been identified within breast cancer cells. Whether these genes are activated (or present) within a breast cancer has been shown to be able to predict a possible outcome in patients with breast cancer. This allows us to look at a particular patient and get a better handle on what her true risk of relapse may be. With more certainty and more confidence we are able to avoid the side effects of chemotherapy.
Two examples of how this test helps oncologists are represented by two different patients that I have seen over the last 2 weeks. The first woman is a young woman who is in her early 40’s. Her sister developed breast cancer approximately five years ago. She had an abnormal mammogram and underwent biopsy, lumpectomy & sentinel lymph node biopsy. The pathology revealed a small, less than a centimeter tumor with no lymph nodes involved. My initial recommendation to her was that this tumor could likely be handled without chemotherapy. However, I recommended that we have the Oncotype DX test performed. The Oncotype DX test came back with a very high possibility of reoccurrence. This result allowed me with confidence to counsel her that her risk is significant( as high as possibly 30-40% chance of this cancer coming back). With this information, it was easier to recommend chemotherapy. The second patient was a lady who was in her late 40’s, with a very similar sized tumor and early stage tumor. In this patients case her Oncotype DX came back very low and I felt very comfortable treating this lady with just anti-estrogen therapy and avoiding the toxicities of IV chemotherapy.
These types of tests are the wave of the future. Our ability to be able to determine which patients are at greatest risk for relapse will continue to be further defined as additional tests become available. These types of tests will be seen within the next few years in colon cancer and possible in prostate cancer. This should allow us to decrease the amount of chemotherapy that we give to patients and to treat our patients with more accuracy and confidence. These tests are one of the most exciting advances in the treatment of cancer and they makes me look forward to increasingly improved outcomes in cancer patients.
There have been several events that have been ongoing recently that have illustrated to me how incredibly miraculous the human body is. The first one is the traveling display of human bodies that has been traveling across the country. These cadavers that have been so exquisitely dissected showing an amazing amount of human anatomy. The display is able to show the internal workings of bodies. They are an incredible display of the beautiful interworkings of the human body even if they are "lifeless".
In stark contrast to this display, we’ve all witnessed the incredible beauty that is the Olympics. Seeing these incredible athletes and the things that they are able to do has to inspire an absolute sense of wonderment. From every corner of the world, athletes have come together and have done incredibly amazing feats. From the swimming pool, to the track, to the shooting ranges, to the beaches we have seen athletes, some of which are incredibly well in to thier 40’s perform at a level that can only be described as amazing.
One of the reasons why I believe that medicine has kept me so interested and riveted over the years is the absolute amazement that I have for the human body. What are bodies are able to withstand every single day amazes me. The human body is adaptable, flexible and resilient. If you have ever witnessed a person who has been treated for leukemia and watch them go through their initial round of chemotherapy, you can’t help but be amazed by the extreme strength that the human body possesses. Surviving without an immune system, no white cells, no red cells, attacked by any bacteria that happens to comes by. The way these patients are able to survive and recover, are examples of the endurance and strength of the body. I really believe that we should all celebrate the wonderful gift of life that are our bodies.
