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The State Of The Cancer Nation

NPR Health Blog - Fri, 04/17/2015 - 11:30am
The State Of The Cancer Nation April 17, 201511:30 AM ET Matt Stiles $(function() { var pymParent = new pym.Parent( 'responsive-embed-cancer-obesity-rate', 'http://apps.npr.org/dailygraphics/graphics/cancer-obesity-rate/child.html', {} ); });

While a cure for cancer remains elusive, we already know how to keep many cases of the disease from developing in the first place.

People can reduce cancer risks by keeping a healthful weight and avoiding cigarettes.

But smoking, obesity and other major cancer risk factors remain common, and they still vary widely across the country.

Researchers working with the American Cancer Society recently compiled nationwide survey data on rates of smoking, obesity, lack of exercise and poor diet — all factors that significantly increase lifetime risks of developing or dying from cancer.

The researchers also looked at the adoption of early prevention methods, such as cancer screenings, skin protection and vaccinations.

Find other stories about the state of cancer in the U.S. in the Living Cancer series at WNYC.org.

WNYC

What did they find? A mixed bag of incremental progress that, in some cases, depends on where Americans live, their race or ethnicity, their socioeconomic status — and, of course, whether they have health insurance. The researchers relied on data collected by the Centers for Disease Control and Prevention.

"Much of the suffering and death from cancer could be prevented by more systematic efforts to reduce tobacco use, improve diet, increase physical activity, reduce obesity and expand the use of established screening tests," the authors wrote in the biennial report.

The research focuses on the most common — and preventable — risk factors for cancer, with some cross tabulations by gender, age and other variables. (You can read those here).

The society estimates that about 1.6 million people in the U.S. will develop cancer this year. Topping the list of risk factors is tobacco use, particularly smoking, which could contribute to as many as 170,000 cancer deaths in the U.S. this year, according to the society.

Overall, adult smoking rates are down: from 23.5 percent in 1999 to 17.8 percent today. The report found that rates have fallen among all education levels, but particularly among people with undergraduate and graduate degrees.

In general, the state-by-state prevalence of the risk factors varied widely (view a complete table at the bottom of this post). That's true with smoking: Only 10 percent of adults in Utah reported being current smokers, for example, compared with 27.3 percent of those in West Virginia.

This map shows the variation, with many states in the South leading the country in smoking rates:

$(function() { var pymParent = new pym.Parent( 'responsive-embed-cancer-smoking-rate', 'http://apps.npr.org/dailygraphics/graphics/cancer-smoking-rate/child.html', {} ); });

Obesity, poor nutrition and physical inactivity are also major risk factors for cancer, second only to smoking.

In 2013, more than two-thirds of Americans were overweight or obese. The prevalence of weight problems increased rapidly after the mid-1970s but has stabilized in recent years, according to the report.

Like smoking, obesity varies by state — again with higher rates in parts of the South. (See map at top of post.) About 21 percent of adults in Colorado are obese, compared with 35.1 percent of those in Mississippi, which has the highest rates in the country.

The researchers found that the proportion of Americans who meet physical activity and nutrition guidelines remains low. For example, only 15 percent of adults report eating three or more servings of vegetables each day.

The three maps below show the rates for adults who reported getting no leisure-time physical activity for 30 days — as well as those who reported not eating at least two daily servings of fruit or three daily servings of vegetables.

(Darker shades in all these maps show higher instances of behaviors that increase risk for cancer. With smoking, obesity and lack of exercise, higher rates are represented with darker shades. With fruit and vegetable consumption guidelines, however, areas with places with lower rates are in darker shades.)

$(function() { var pymParent = new pym.Parent( 'responsive-embed-cancer-exercise-rate', 'http://apps.npr.org/dailygraphics/graphics/cancer-exercise-rate/child.html', {} ); }); $(function() { var pymParent = new pym.Parent( 'responsive-embed-cancer-fruit-rate', 'http://apps.npr.org/dailygraphics/graphics/cancer-fruit-rate/child.html', {} ); }); $(function() { var pymParent = new pym.Parent( 'responsive-embed-cancer-veggie-rate', 'http://apps.npr.org/dailygraphics/graphics/cancer-veggie-rate/child.html', {} ); });

In addition to documenting the risk factors, the researchers also studied the prevalence of prevention efforts, such as breast and colorectal screenings, abstaining from tanning machines and vaccinations associated with decreases in some cancers.

The researchers note that the rate of colorectal screening remains lower than that of breast and cervical cancer.

Screening rates vary by geography and socioeconomic classes as well. About 60 percent of people age 50 or older have received a recent colorectal test, which can detect cancers, of course, but also help prevent them by spotting precancerous polyps. But only 22 percent of people without health insurance have received such a test.

"There's a lot of room for improvement across all cancer screening types among the uninsured and among lower socioeconomic populations," said Stacey Fedewa, director of risk factor screening and surveillance at the American Cancer Society.

We've compiled all the risk data in the table below which, like the maps, uses darker shades to represent higher instances of risk. The table is separated by region, which makes it easy to see how some areas of the country face higher risk factors than others. You can read the full report, with highlights annotated by NPR, here.

$(function() { var pymParent = new pym.Parent( 'responsive-embed-cancer-risk-factors', 'http://apps.npr.org/dailygraphics/graphics/cancer-risk-factors/child.html', {} ); });

Matt Stiles, a former data editor on NPR's visuals team, is a freelance writer based in Seoul, South Korea. Follow him @stiles.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Top Hospital Ratings Prove Scarce In Medicare's Latest Tally

NPR Health Blog - Fri, 04/17/2015 - 10:27am
Top Hospital Ratings Prove Scarce In Medicare's Latest Tally April 17, 201510:27 AM ET

Partner content from

Jordan Rau

Vacuum cleaners get them. Movies get them. Now hospitals are being given star ratings to help patients decide which ones to use.

On Thursday the federal government awarded its first star ratings to hospitals based on the opinions of patients. Some of the nation's most lofty hospitals—the ones featured in best hospital lists—received mediocre ratings, while the maximum number of stars often went to small, regional hospitals and others that specialize in lucrative surgeries.

Evaluating hospitals is becoming increasingly important as more insurance plans offer patients limited choices. Medicare already uses stars to rate nursing homes, dialysis centers and private Medicare Advantage insurance plans. Medicare publishes dozens of quality measures on its Hospital Compare website, but many are tough to decrypt. Most consumers don't use them.

Additional Information:

Many in the hospital industry fear Medicare's 5-star scale won't accurately reflect quality and may place too much weight on patient reviews, which are just one measurement of hospital quality. Medicare also reports the results of hospital care, such as how many patients died or got infections during their stay, but those are not yet assigned stars.

"We want to expand this to other areas like clinical outcomes and safety over time, but we thought patient experience would be very understandable to consumers so we started there," Dr. Patrick Conway, chief medical officer for the Centers for Medicare & Medicaid Services, said in an interview.

Medicare's new summary star rating, posted on Hospital Compare, is based on 11 facets of patient experience, including how well doctors and nurses communicated, how well patients believed their pain was addressed, and whether they would recommend the hospital to others.

In assigning stars, Medicare compared hospitals against each other, essentially grading on a curve. It noted on Hospital Compare that "a 1-star rating does not mean that you will receive poor care from a hospital" and that "we suggest that you use the star rating along with other quality information when making decisions about choosing a hospital."

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The American Hospital Association offered its own caution, saying: "There's a risk of oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons."

Nationally, Medicare awarded the top rating of five stars to 251 hospitals, about 7 percent of all the hospitals Medicare judged, a Kaiser Health News analysis found. Many are small specialty hospitals that focus on lucrative elective operations such as spine, heart or knee surgeries. They have traditionally received more positive patient reviews than have general hospitals, where a diversity of sicknesses and chaotic emergency rooms make it more likely patients will have a bad experience.

A few five-star hospitals are part of well-respected systems, such as the Mayo Clinic's hospitals in Phoenix, Jacksonville, Fla., and New Prague, Minn. Mayo's flagship hospital in Rochester, Minn., received four stars.

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Medicare awarded three stars to some of the nation's most esteemed hospitals, including Cedars-Sinai Medical Center in Los Angeles, NewYork-Presbyterian Hospital in Manhattan, and Northwestern Memorial Hospital in Chicago. The government gave its lowest rating of one star to 101 hospitals, or 3 percent. (You can see all hospital ratings here.)

On average, hospitals scored highest in Maine, Nebraska, South Dakota, Wisconsin and Minnesota. Thirty-four states had no one-star hospitals.

Hospitals in Maryland, Nevada, New York, New Jersey, Florida, California and the District of Columbia scored lowest on average. Thirteen states and the District of Columbia did not have a single five-star hospital.

In total, Medicare assigned star ratings to 3,553 hospitals based on the experiences of patients who were admitted between July 2013 and June 2014. Medicare gave out four stars to 1,205 hospitals, or 34 percent of those it evaluated. Another 1,414 hospitals — 40 percent — received three stars, and 582 hospitals, or 16 percent, received two stars. Medicare did not assign stars to 1,102 hospitals, primarily because not enough patients completed surveys during that period.

While the stars are new, the results of the patient satisfaction surveys are not. They are presented on Hospital Compare as percentages, such as the percentage of patients who said their room was always quiet at night. Often, hospitals can differ by just a percentage point or two, and until now Medicare did not indicate what differences it considered significant. Medicare also uses patient reviews in doling out bonuses or penalties to hospitals based on their quality each year.

Some groups that do their own efforts to evaluate hospital quality questioned whether the new star ratings would help consumers. Evan Marks, an executive at Healthgrades, which publishes lists of top hospitals, said it was unlikely consumers would flock to the government's rating without an aggressive effort to make them aware of it.

"It's nice they're going to trying to be more consumer friendly," he said. "I don't see that the new star rating itself is going to drive consumer adoption. Ultimately, you can put the best content up on the Web, but consumers aren't going to just wake up one day and go to it."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Use Of E-Cigarettes Triples Among U.S. Teens

NPR Health Blog - Thu, 04/16/2015 - 6:19pm
Use Of E-Cigarettes Triples Among U.S. Teens April 16, 2015 6:19 PM ET

Nicotine exposure at a young age "may cause lasting harm to brain development," warns Dr. Tom Frieden, chief of the Centers for Disease Control and Prevention.

iStockphoto

A national survey confirms earlier indications that e-cigarettes are now more popular among teenage students than traditional cigarettes and other forms of tobacco, federal health officials reported Thursday.

The findings prompted strong warnings from Dr. Tom Frieden, head of the Centers for Disease Control and Prevention, about the effects of any form of nicotine on young people.

"We want parents to know that nicotine is dangerous for kids at any age," Frieden said.

CDC/CDC National Youth Tobacco Survey

"Adolescence is a critical time for brain development," he added, in a written statement. "Nicotine exposure at a young age may cause lasting harm to brain development, promote addiction and lead to sustained tobacco use."

The statistical findings, published in this week's issue of Morbidity and Mortality Weekly Report, come from the CDC's National Youth Tobacco Survey. The latest survey found that the use of e-cigarettes increased from 1.1 percent in 2013 to 3.9 percent in 2014 among middle school students, and from 4.5 percent to 13.4 percent among high school students. That translates to a total of 450,000 middle school students now using e-cigs, alongside 2 million high school students

The findings are similar to those from a study reported in December.

The CDC survey also found that hookah use doubled among middle schoolers and high school students, while use of traditional cigarettes fell for high school students and remained the same for middle school students.

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The new evidence comes as the Food and Drug Administration is deciding how strictly to regulate e-cigarettes. The devices heat a nicotine-laced fluid, which then becomes a vapor that users inhale. While many doctors say the vapor of e-cigarettes is likely less damaging than the smoke of burned tobacco leaves, there is intense debate about how safe e-cigarettes are. Some public health researchers say the electronic devices may be useful for helping some smokers give up traditional cigarettes. But many also fear the devices may hook a new generation on nicotine and lead them to start smoking traditional cigarettes.

"The release of this survey couldn't be better timed," said Nancy Brown of the American Heart Association in a written statement. "The take-away message is loud and clear: Tobacco regulations need to be finalized now. We cannot stand by while more and more youth put themselves at risk for heart disease, stroke or even an early death."

But the makers of e-cigarettes argue that the devices may be helping drive down the rate of regular cigarette use among teens.

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"While the use of vapor products by teens should be discouraged, the data is clear that as teen experimentation with vaping has grown over the last three years, youth smoking has experienced the largest decline in the history of the ... survey," Gregory Conley, of the American Vaping Association, told Shots in an email.

"This dramatic fall in teen smoking should be part of the discussion," Conley said, "but the CDC deemed this finding to not be worthy of a single line in their press release. That is not surprising, as it would interfere with the CDC's evidence-free attempts to paint e-cigarettes as a potential gateway to traditional cigarettes."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Scientists Probe Puppy Love

NPR Health Blog - Thu, 04/16/2015 - 2:45pm
Scientists Probe Puppy Love April 16, 2015 2:45 PM ET Listen to the Story 3 min 26 sec  

A direct, friendly gaze seems to help cement the bond of affection between people and their pooches.

Dan Perez/Flickr

It's a question that bedevils dog owners the world over: "Is she staring at me because she loves me? Or because she wants another biscuit?"

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Research published Thursday in the journal Science suggests that love (or something close) could be behind that stare. The work shows that when dogs and their people gaze into each other's eyes, all get a boost in their circulating levels of oxytocin — a hormone thought to play a role in trust and emotional bonding.

The results suggest that both dogs and people feel it, something few dog owners would doubt.

"It's really cool that there's actually some science to back this up now," says Evan MacLean, an evolutionary anthropologist and co-director of Duke University's Canine Cognition Center.

For thousands of years, humans have bred dogs for obedience, and that has altered their brains as well. For example, MacLean says, dogs are excellent at understanding gestures like pointing. They're also good with language.

But have humans also bred dogs for affection?

"Well, it's a harder one to get at, partially because emotions are so subjective," MacLean says. For instance, many owners say their dog feels guilty after behaving badly, but that's not true.

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"There have been good studies to show that, actually, what's happening in those situations is that dogs are ... just responding to people," he says. In other words, the dog looks guilty to you because you look angry to the dog.

A team led by Takefumi Kikusui, at Azabu University's school of veterinary medicine in Japan, has now found a more quantitative measure of emotion. The scientists let owners and dogs interact. And rather than just watching each pair, the team took urine samples from the people and the dogs.

"They measured oxytocin, which is a hormone that has been very associated with trust and social bonds," says MacLean, who was not part of the research team.

Oxytocin is the same bonding hormone thought to give parents warm fuzzies when looking at their infants.

Researchers found that when dogs stared into their owner's eyes, oxytocin levels rose in both the people and the dogs. The same was not true for wolves, who were observed with their handlers. The team also found that when dogs were given a shot of oxytocin, they would stare into the eyes of their owners for a longer period, and that gazing, in turn, would boost the oxytocin levels in the owners. That increase points to a hormonal feedback loop between the dogs and the humans.

Taken together, MacLean says, the findings suggest a special bond between dogs and people — a bond that may have evolved as humans bred them. "I'm perfectly happy saying that we can love dogs, and they can love us back," MacClean says, "and oxytocin is probably a piece of how that happens."

But not everyone is buying this hormonal connection.

"There is a fashion in science at the moment, to identify changes in hormone levels with changes in emotional and feeling states," says Clive Wynne, a psychologist at Arizona State University who studies how dogs and people interact.

In fact, oxytocin is not always associated with love, he points out. The hormone can also be linked to feelings of emotional isolation — even aggression in some animals. The wolves used in the study didn't make a lot of eye contact, Wynne says. If they had, their oxytocin might have gone up too.

But Wynne adds that, oxytocin or no, he believes the bonds between dogs and humans are real.

"I think the best evidence that any dog lover has that their dog loves them is what the dog does was when it's around them," Wynne says. "We're entitled to trust the evidence of our own senses."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Study: Insurers Fail To Cover All Prescribed Contraceptives

NPR Health Blog - Thu, 04/16/2015 - 1:38pm
Study: Insurers Fail To Cover All Prescribed Contraceptives April 16, 2015 1:38 PM ET

Will the health plan pay for the contraceptives the doctor prescribes?

MediaforMedical/Emmanuel Rogue/Getty Images

Some women may be paying hefty fees for birth control pills, vaginal rings and emergency contraception, despite a federal requirement that insurers pay their full cost. And some women only have coverage for a less effective type of emergency contraception, according to a report released Thursday by the Kaiser Family Foundation.

The analysis looked at 20 health insurers in five states and found companies that provided limited or no coverage for some forms contraception. In some cases, the insurers imposed copays or required women to pay the full cost of a drug.

For example, seven insurers didn't pay the full cost of vaginal rings, and one company does not pay for ParaGard, the only nonhormonal IUD available to women. It can cost up to $1,000.

"That's a flagrant violation of the law," says Gena Madow, a spokeswoman for Planned Parenthood.

Nevertheless, Planned Parenthood said the study revealed many positive trends. "Many plans are meeting the law and covering the full range of contraceptive methods with no cost sharing and no medical management restrictions," the group said in a statement. "However, the report also shows that stronger enforcement of the birth control benefit is critical."

Consider the case of ella, an emergency contraceptive. A recent study found that the pill could be more effective at preventing pregnancies than Plan B, the traditional and more widespread emergency contraceptive, particularly in heavier women.

Despite that finding, the Kaiser study showed that several plans still only cover Plan B, meaning women may face a difficult choice: get a less effective emergency contraceptive free, or pay for a better one.

America's Health Insurance Plans, an industry trade group, says insurers aren't doing anything illegal because federal guidelines give them some latitude. "The guidance makes clear that plans do not have to cover every single form of birth control," says Clare Krusing, a spokesperson for AHIP.

Krusing says the guidance makes clear that insurers can use "reasonable medical management" techniques to limit costs, such as requiring patients to pay co-pays for brand name drugs, when lower-cost generic versions are available.

"If health plans were required to cover every single kind of contraception, premiums would become more expensive, and insurance plans would risk becoming unaffordable," she says.

Insurers offer an appeals process, Krusing says, so that women can get special coverage for contraceptives prescribed by their doctors that don't happen to be on health plans' preferred lists, or formularies.

But Planned Parenthood says the insurers aren't, in fact, meeting guidelines laid out by the Institute of Medicine, Centers for Disease Control and Prevention and Department of Health and Human Services.

The group says it is asking the government to make sure that insurance companies comply with the law.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Men Strive To Give More To Charity When The Fundraiser Is Cute

NPR Health Blog - Thu, 04/16/2015 - 1:00pm
Men Strive To Give More To Charity When The Fundraiser Is Cute April 16, 2015 1:00 PM ET

We donate to charities for lots of reasons: because we're generally magnanimous people, because we care deeply about certain issues or because it's the only way to get Meg to stop talking about the plight of the endangered proboscis monkey.

And for men, there may be another force at play: a subconscious desire to impress the ladies.

Researchers in the United Kingdom reviewed thousands of online donation pages from the 2014 Virgin London Marathon. Runners participating in the marathon usually put up a fundraising page where they can raise money for a charity of their choice. And donations are made publicly, so the researchers could keep track of donors' names and how much they contributed.

It turned out that everyone was a little competitive on online donation platforms: people on average gave about £10 more after seeing others' large donations.

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But men donating to attractive female fundraisers were extra competitive. They contributed £28 more than the last guy, on average.

"The results were quite surprising, actually, in that they were completely in line with the theory that men are hardwired to act competitively in this way," says Sarah Smith, an economist at the University of Bristol and a one of the researchers behind the study.

The researchers came to this conclusion by first having independent reviewers rate the attractiveness of each fundraiser's profile photo. They then looked at how much people donated to each fundraiser. When someone donated £50 or more, the researchers studied how subsequent donors reacted.

Attractive fundraisers raised more money, as did those whose profiles featured nice smiles. That worked for both male and female fundraisers. "Maybe not everybody can be the most attractive, but everybody can give a smile," Smith says. "That's something to keep in mind the next time you're trying to raise money."

This doesn't mean that people who donate to charities don't have noble intentions, Smith notes. People usually decide to donate because they care about a cause. But this subconscious competitiveness may be subtly influencing how much they choose to donate.

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It's also worth noting that the researchers weren't able to account for the donors' sexual preferences or relationship status. "So we just don't know how being married or being attracted to other men would affect the competitiveness," Smith says. "But I think it's safe to assume if we excluded men have no incentive to compete for the fundraiser, we probably would have seen even more competiveness."

"This sort of thing happens in the animal kingdom all the time," says Nichola Raihani, an evolutionary biologist at University College London who worked with Smith on the paper. "The classic example would be the peacock. The male is so showy — trying to impress with his huge plume. And the female really holds all the cards. It's the same thing here, in the context of male donors."

By donating to charities, men signal that they're caring and generous, as well as wealthy, Raihani says. "We found that women aren't competitive with each other in the same way in this context," she notes. "And that may be because men and women prioritize different things when evaluating potential partners. Studies show that women are more likely to prioritize cues that the man can be a good provider."

Culture and hormones can help explain the behavior as well, notes David Geary, an evolutionary psychologist at the University of Missouri who wasn't involved with the study, which was published Thursday in Current Biology.

"Basic competitiveness is evolved and related in part to testosterone," Geary said in an email. But how the competitiveness is expressed depends on context. "You'd only find competitive donations in wealthy societies," he adds. Other cultures may define success in other ways.

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Letters About Dense Breasts Can Lead To More Questions Than Answers

NPR Health Blog - Thu, 04/16/2015 - 10:57am
Letters About Dense Breasts Can Lead To More Questions Than Answers April 16, 201510:57 AM ET

Partner content from

Barbara Feder Ostrov

Caryn Hoadley, 45, from Alameda, Calif., with her two children. Hoadley received a letter that said her mammogram was clean but that she has dense breast tissue, which has been linked to higher rates of breast cancer

Courtesy of Poppins Photography

Earlier this year, Caryn Hoadley received an unexpected letter after a routine mammogram.

The letter said her mammogram was clean but that she has dense breast tissue, which has been linked to higher rates of breast cancer and could make her mammogram harder to read.

"I honestly don't know what to think about the letter," said Hoadley, 45, who lives in Alameda, Calif. "What do I do with that information?"

Millions of women like Hoadley may be wondering the same thing. Twenty-one states, including California, have passed laws requiring health facilities to notify women when they have dense breasts. Eleven other states are considering similar laws and a nationwide version has been introduced in Congress.

The laws have been hailed by advocates as empowering women to take charge of their own health. About 40 percent of women have dense or extremely dense breast tissue, which can obscure cancer that might otherwise be detected on a mammogram.

But critics say the laws cause women unnecessary anxiety and can lead to higher costs and treatment that doesn't save lives or otherwise benefit patients.

"While I think the intent of these laws is well meaning, I think their impact is going to be a significant problem, where we end up doing more harm than good," said Dr. Laura Esserman, a University of California, San Francisco surgeon and breast cancer specialist.

Typically, the laws require a notice be sent to a woman if she has dense breast tissue seen on a mammogram. Some notifications suggest that a woman talk to her doctor about additional screening options.

But in some states, not including California, the laws go further by requiring health providers to offer a supplemental screening, such as an ultrasound, to women with dense breasts even if their mammograms are clean. Connecticut, Illinois and Indiana even require insurers to pay for screening ultrasound after mammography if a woman's breast density falls above a certain threshold.

Otherwise insurers don't routinely cover supplemental screening for women with clean mammograms, even if they have dense breasts. The Affordable Care Act doesn't require it.

The problem, Esserman says, is that no medical consensus exists on whether routine supplemental screening for women with dense breasts is worthwhile.

A recent Annals of Internal Medicine study using computer modeling found that offering an ultrasound to women with dense breasts after a clean mammogram wouldn't significantly improve breast cancer survival rates but would prompt many unnecessary biopsies and raise health care costs.

Another study conducted in Connecticut after its notification law went into effect found that supplemental ultrasound screening for women with dense breasts did find a few additional cancers — about 3 per 1,000 women screened. But the probability that such screenings would find life-threatening cancers was low.

Dense breast notification laws have added another layer of complexity to the long-running and often emotional debate over how best to screen women for breast cancer.

Breast cancer is the second most common form of cancer among American women, behind skin cancers, and the second leading cause of cancer death. An estimated 231,840 U.S. women will be diagnosed with invasive breast cancer in 2015, according to the American Cancer Society.

About 38.5 million mammograms are performed each year in an attempt to find signs of cancer early enough to treat it successfully. Emerging technologies like tomosynthesis, a 3-D digital X-ray of the breast, may become cheap enough to replace conventional mammography and make the notification laws irrelevant, but their widespread use is years away.

For a long time, women were advised to start yearly mammograms at about age 40, but in 2009, the U.S. Preventive Services Task Force issued controversial recommendations that most women without a family history of breast cancer or other risk factors should wait until age 50 to begin mammograms, and repeat them every two years. Patient advocates decried the recommendations as rationing preventive health care for women.

In the meantime, Nancy Cappello, an education administrator from Connecticut, was pushing to pass what became the nation's first dense breast notification law. Just two months after a clean mammogram, she had been diagnosed with breast cancer that had spread to her lymph nodes. She had extremely dense breasts, something her radiologist knew but Cappello wasn't told. Dense breasts have more glandular and fibrous tissue, which block the X-rays used in mammograms more than fatty tissue does.

Eventually, she founded a patient advocacy organization and took her campaign national.

"There's no evidence that we're scaring women. Most women I've talked to are very happy to get these notifications," said Cappello, whose cancer is in remission. "We want to make informed decisions ... to have a better chance of surviving the disease."

Dr. Jane Kakkis, a breast cancer surgeon in Fountain Valley, Calif., supports dense breast notification laws and testified in front of Nevada lawmakers before that state passed its law in 2013. Like Cappello, she dismisses concerns that the notification laws will cause undue fear.

"You have no idea what fear is until you have a cancer that's already spread to your lymph nodes," Kakkis said. "Patients will say in disbelief, 'But I just had a mammogram and it was normal.' They can't believe how advanced it is. Dense breast notification is bringing up a whole conversation about risk that wouldn't come up otherwise."

Catharine Becker of Fullerton, Calif., was diagnosed with stage 3 breast cancer at 43 despite having a clean mammogram. The mother of three didn't know she had dense breast tissue until after she was diagnosed.

Heidi de Marco/Kaiser Health News

One of Kakkis' patients, Catharine Becker of Fullerton, was diagnosed with breast cancer six years ago. She'd felt a lump three months after a clean mammogram. Because Becker had a family history of breast cancer – her mother died from the disease – she started mammograms early, at age 35. But they never showed any cancer. Until she was diagnosed, she didn't know she had dense breast tissue.

"To be told at age 43 I had stage 3 cancer after a clean mammogram was really a shock," Becker said, crediting her survival to breast self-exam and her doctors. "I'd rather have more information than less."

Women with moderately dense breasts have about a 20 percent higher chance of getting breast cancer than women who don't. Those with the highest-density breasts have about double. To put these numbers into perspective, if an average 50-year-old woman has a 2.38 percent chance of getting cancer in the next 10 years of her life, a woman with the highest density breasts would have a 4.76 percent chance of being diagnosed.

New ways of classifying dense breast tissue could put even more women in the category of receiving dense breast notifications, said Dr. Priscilla Slanetz, who recently wrote in the New England Journal of Medicine questioning the effectiveness of dense breast notification laws.

One reason she wrote the article, she said, was "in our state [Massachusetts] very few of our primary care providers have any knowledge about breast density and strengths and limitations of these different tests" for supplemental screening.

The same may hold true in California, where a small survey of primary care doctors found that only half of them had heard of the state's 2013 dense breast notification law and many felt they didn't have enough education to address what breast density meant for their patients.

On this point, both supporters and critics of the laws agree: Doctors need better tools to help their patients identify their individual cancer risks.

To that end, specialists are developing more personalized screening protocols that result in low-risk women being screened less often than higher-risk women.

"It's not rationing, it's being rational," said Esserman, who has a $14 million grant to study the issue. "We should be testing different approaches for screening women with dense breasts, and then pass legislation once we know what to do."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Tylenol Might Dull Emotional Pain, Too

NPR Health Blog - Thu, 04/16/2015 - 3:49am
Tylenol Might Dull Emotional Pain, Too April 16, 2015 3:49 AM ET Angus Chen Listen to the Story 3 min 50 sec   Paul Taylor/Getty Images

A common pain medication might make you go from "so cute!" to "so what?" when you look at a photo of a kitten. And it might make you less sensitive to horrifying things, too. It's acetaminophen, the active ingredient in Tylenol. Researchers say the drug might be taking the edge off emotions — not just pain.

"It seems to take the highs off your daily highs and the lows off your daily lows," says Baldwin Way, a psychologist at Ohio State University and the principal investigator on the study. "It kind of flattens out the vicissitudes of your life."

The idea that over-the-counter pain pills might affect emotions has been circulating since 2010, when two psychologists, Naomi Eisenberger and Nathan DeWall, led a study showing that acetaminophen seemed to be having both a psychological and a neurological effect on people. They asked volunteers to play a rigged game that simulated social rejection. Not only did the acetaminophen appear to be deflecting social anxieties, but it also seemed to be dimming activity in the insula, a region of the brain involved in processing emotional pain.

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"But [the insula] is a portion of the brain that seems to be involved in a lot of things," Way says. In older studies, scientists saw that people with damage in their insula didn't react as strongly to either negative or positive images. So Way and one of his students, Geoffrey Durso, figured that if acetaminophen is doing something to the insula, then it might be having a wider effect, too.

The researchers gave about 40 people the equivalent of two extra-strength Tylenols and gave another 40 people a placebo. Then they asked the volunteers to rate pictures ranging from weeping, starving children to kids playing with kitties on how pleasant or depressing each photo was and how powerful they found the image.

On average, the people who'd taken the acetaminophen said they felt nearly 20 percent less happy when they saw the delightful photos and nearly 10 percent less sad when they saw the dreadful photos compared to those who'd taken the placebo. The same was true for their ratings for the power of each image. The results were reported this month in Psychological Science,

"It's a surprising finding," says Nathan DeWall, a professor of psychology at the University of Kentucky who was not involved in the study. Typically, he says, we think of acetaminophen as numbing painful experiences. Instead, DeWall says this study suggests that the drug may have a broader impact by muffling all emotions.

That's intriguing, for sure, but this is a small preliminary study, and Durso and Way admit the effects they measured were small, too.

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For one thing, it's unclear how acetaminophen might be manipulating our minds. "I'd say there's a common mechanism — a common lever, if you will, where one can affect both positive and negative systems in the brain," Way speculates. Or maybe there are two levers to dampen each system, and the pain medication just seizes them both at the same time, numbing our entire emotional connection to the world. "The bottom line is we don't know," Ways says.

It's also a puzzle to Dr. Lewis Nelson, a medical toxicologist at NYU Langone Medical Center who says though this new study is well done, he's not entirely convinced that acetaminophen is having a measurable effect on people's emotions.

"I'd like to know more about how it might happen," he says. "One way to think about things in medicine is to understand the biological plausibility."

And while science works to figure that out, popping a Tylenol when your nerves get a little jangly isn't a good idea, says Nelson, who's also an emergency room doctor. "This is not the kind of drug we want people to use to any sort of excess."

The greatest value from the study might be in what acetaminophen could lend toward future research. "The door here has been propped open in ways we haven't recognized," says social psychologist Steve Heine, whose lab at the University of British Columbia has also been studying acetaminophen. "Both as a tool for helping us identify how the brain works, but also for practical purposes. There might be some real consequences to having acetaminophen work in your system."

If what Way and Durso are saying is true, he ventures, there could be other effects that acetaminophen has on our minds that we have yet to uncover. But for now, what the drug is doing and how deeply it might influence emotion is a matter of speculation.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Why Knuckles Crack

NPR Health Blog - Wed, 04/15/2015 - 4:59pm
Why Knuckles Crack April 15, 2015 4:59 PM ET Listen to the Story 3 min 28 sec  

NPR intern Poncie Rutsch takes a crack at making a big sound.

Meredith Rizzo/NPR

Scientists think they may have solved an old question about the cracking of knuckles: Why does it make that sound?

The crack apparently comes from a bubble forming in the fluid within the joint when the bones separate, according to a study published Wednesday. It's like a tiny air bag inflating.

The findings confirm the original theory about knuckle-cracking, which was first proposed in 1947 but challenged in the 1970s.

According to Greg Kawchuk, a professor of rehabilitation medicine at the University of Alberta, that second group of scientists came along and said, " 'No, no, no — wait! We think what's happening is, the gas bubble forms but then it subsequently collapses. That's what makes the big sound.' "

While many people accepted the bubble-bursting theory, no one was sure. So Kawchuk and a team of scientists figured out a little test, enlisting the help of a pal who is really good at cracking his knuckles.

"We called our colleague the 'Wayne Gretzky of finger-cracking,' " Kawchuck says. "He can make this happen in all 10 of his fingers."

They asked the volunteer to put his hand inside a special type of MRI scanner, and made a movie of the inside of his knuckles as they pulled on the end of each finger to make it crack.

"We've been calling it the 'Pull My Finger Study,' " Kawchuk says.

What they saw was clear: The cracking sound comes when a bubble forms between the bones of the knuckle joint — not when it collapses.

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"Our jaws hit floor," he says. "This is the exact answer. It feels pretty great."

Other researchers praised the study, which appears in the online journal PLOS ONE.

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"This is the first time we're actually seeing what's going on inside the joint when a knuckle is being cracked," says Dr. Kevin deWeber, who studies sports medicine in Vancouver, Wash. "It's really exciting."

DeWeber says the discovery also reinforces previous research that challenged a common misconception about knuckle-cracking — that it causes arthritis.

"It's mostly an urban myth ... perpetuated by mothers who are sick of hearing their kids crack their knuckles," deWeber says. He thinks cracking knuckles might actually be good for the joints — sort of a massage of the cartilage.

"This study helps us understand the biomechanics of the knuckle-cracking event," deWeber says. "We are reassured that nothing harmful is happening inside. And ... maybe something helpful is happening."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Personalizing Cancer Treatment With Genetic Tests Can Be Tricky

NPR Health Blog - Wed, 04/15/2015 - 2:49pm
Personalizing Cancer Treatment With Genetic Tests Can Be Tricky April 15, 2015 2:49 PM ET Listen to the Story 3 min 55 sec  

Sequencing the genes of a cancer cell turns up lots of genetic mutations — but some of them are harmless. The goal is to figure out which mutations are the troublemakers.

Kevin Curtis/Science Source

It's becoming routine for cancer doctors to order a detailed genetic test of a patient's tumor to help guide treatment, but often those results are ambiguous. Researchers writing in Science Translational Medicine Wednesday say there's a way to make these expensive tests more useful.

Here's the issue: These genomic tests scan hundreds or even thousands of genes looking for mutations that cause or promote cancer growth. In the process, they uncover many mutations that scientists simply don't know how to interpret — some may be harmless.

"What we found is, you essentially get a lot of inaccurate information," says Dr. Victor Velculescu, a professor of oncology and pathology and co-director of cancer biology at the Johns Hopkins Kimmel Cancer Center.

The consequences of misinterpreting these results could be significant.

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"You can imagine patients being placed on a particular therapy, with all the side effects of that therapy but without any of the benefits," Velculescu says. "You can imagine that it prevents the patient from getting the right therapy. And then, finally, there are the additional costs of having therapies that aren't really useful in any way."

Velculescu and his colleagues now report that about half of all people whose tumors are examined with a genome test get results that are potentially misleading.

They argue there's a way to refine these results: by studying the DNA of a person's healthy tissue at the same time the tumor is sampled. That way, doctors can distinguish mutations that are unique to the cancer and more likely to be related to the disease.

Velculescu has an economic reason for making this argument. He co-founded a company that tests healthy cells alongside tumor cells. That said, other scientists do agree with his fundamental point.

But they also say that existing tests are actually quite accurate when used appropriately.

Genomic tests reliably identify mutations that are clearly linked to certain cancers, "and those are the ones that are used clinically for making decisions about what to do for a patient and what's the optimal way to take care of that patient," says Dr. Neal Lindeman, a Harvard University pathology professor who runs a cancer genome program at Dana Farber Cancer Center and Brigham and Women's Hospital.

However, Lindeman says, genetic tests also spot a lot of ambiguous information, and that can sometimes lead people into clinical trials that are wrong for them.

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A comparison with a genetic profile of healthy tissue would add clarity to situations like this, by homing in on mutations that are more likely to be contributing to the cancer.

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At the moment, many companies that perform these genomic tests don't run that additional, expensive comparison. The genome test alone can cost more than $5,000, and a second test of normal tissue would increase that price substantially. Velculescu says insurance often won't pick up that additional cost.

Foundation Medicine, a company that ran more than 25,000 cancer genome tests last year, sorts its results so that doctors can readily distinguish between clear and speculative results.

"I have seen reports from other vendors or institutions where they just throw everything together and that does create this potential where one could be treating the patient on the basis of something that is not a cancer-driving alteration," says Dr. Vincent Miller, the company's chief medical officer. "But we clearly make that distinction."

There's room for this confusion because the booming cancer-genomics industry is not tightly regulated by the Food and Drug Administration.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Some Doctors Still Dismiss Parents' Concerns About Autism

NPR Health Blog - Wed, 04/15/2015 - 12:20pm
Some Doctors Still Dismiss Parents' Concerns About Autism April 15, 201512:20 PM ET Poncie Rutsch

Some doctors aren't up to date on how to assess autism symptoms in very young children.

iStockphoto

Most children with autism get diagnosed around age 5, when they start school. But signs of the developmental disorder may be seen as early as 1 year old.

Yet even if a parent notices problems making eye contact or other early signs of autism, some doctors still dismiss those concerns, a study finds, saying the child will "grow out of it." That can delay diagnosis and a child's access to therapy.

"Autism should be something that primary care pediatricians are really comfortable with, like asthma or ADHD, but it's not," says lead researcher Katharine Zuckerman, a pediatrician at Oregon Health & Science University, whose study was published Tuesday in The Journal of Pediatrics. "If you see a general pediatrician like me, I can't actually diagnose your child with autism."

Diagnosing autism often starts when parents notice subtle differences in their baby's development. The child might not make eye contact as much as other babies do, or he might not be grasping objects at 6 months. Other early signs include not smiling when smiled at, or not responding to a familiar voice.

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To get a better sense of how children with autism get delayed on the road to diagnosis, Zuckerman looked at the Centers for Disease Control's Survey of Pathways to Diagnosis and Services, which includes detailed data about 1,420 children between ages 6 and 17 with autism. She documented three significant dates each child: the date parents first worried; the date they first mentioned their concerns to a physician; and the date the child was diagnosed. She also noted what the parents recalled about the physician's response to their concerns.

Some doctors called for further tests or referred parents to a specialist, while others took no action other than reassuring the parents that their child was normal or it was too early to tell if anything was wrong.

Zuckerman compared the information for children who were eventually diagnosed with an autism spectrum disorder to children with an intellectual disability or developmental delay, two other intellectual problems that first show up in early childhood. About 14 percent more of the children with an autism spectrum disorder received a passive response from the health care practitioner, and were diagnosed about three years later than the children with other intellectual problems.

So what's delaying the pediatricians? Rebecca Landa, the director of the Center for Autism and Related Disorders at the Kennedy Krieger Institute, says there are a number of reasons why health care practitioners don't always jump at the first mention of autism. First, many parents with young children tend to worry over minor problems. Health care practitioners are listening for certain words, and if the parents don't seem particularly alarmed, it's easy to dismiss their concerns.

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And even if parents are persistent, autism is hard to diagnose. The symptoms are subtle, particularly in young children. "People expect that autism [in infancy] is going to look like autism in infancy, and that's not what happens." explains Landa. A baby who sits unsteadily at 6 months may have autism, or he might just be a slow sitter. "Babies do weird things," says Landa.

But perhaps the biggest problem isn't that it's hard to spot a young child with autism, but that most doctors and other health care practitioners aren't trained to identify those early signs.

Researchers knew far less about autism when most doctors practicing today studied medicine. Unless a pediatrician spent her or his residency in a field like neurodevelopmental pediatrics, they wouldn't have been trained to diagnose autism.

The children in the study were diagnosed around age 5, the average age of autism spectrum diagnosis in the U.S. But Zuckerman says that children could be diagnosed much earlier. And an earlier diagnosis means that children and parents can get help learning techniques to make life with autism a little more manageable a little sooner.

If anything, the study points to the need to get resources to physicians so that they can recognize signs of trouble. "We need to give them the skills they need so they can identify kids," says Zuckerman.

The American Academy of Pediatrics recommends that pediatricians screen children at their 18-month checkup and again when the child is between 24 and 30 months old. But it will take a few years for this practice to truly take root.

Meanwhile, Zuckerman says parents can find online tests and videos, so that they have a better idea of that to look for.

"We screen for blood pressure in kids and for vision," says Zuckerman. "There's no reason we can't screen for autism."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

When Keeping A Secret Trumps The Need For Care

NPR Health Blog - Wed, 04/15/2015 - 10:08am
When Keeping A Secret Trumps The Need For Care April 15, 201510:08 AM ET

Will adult children seek care if their parents can find out about it?

Maria Fabrizio for NPR

Dana Lam was insured under her parent's health plan until the end of 2014, thanks to a provision of the Affordable Care Act that allows young adults to stay on family health insurance until they turn 26.

The arrangement worked out well until she needed treatment for depression. Lam knew that if she used her parents' health plan to see a psychotherapist or psychiatrist, her visit would show up on their insurance statements.

She wasn't ready to talk to them about her mental health issues. "I was just so afraid of having that conversation with them," she says.

She was able to use her school's free counseling services instead, but there was a catch. "Medication is really what I needed," Lam says. She couldn't afford to pay for medicine without using insurance, she says, so she didn't take any.

When she graduated, Lam's part-time job didn't come with benefits, so she stayed on her parent's insurance and she stopped getting help of any kind. "I looked around for free mental health care or community centers, but I didn't find much of anything," Lam says.

Now Lam is 26 and teaches English as a second language in Orange County, Calif. She has her own insurance, which she bought on the state exchange. She's getting the help she needs, and she recently told her parents what had been going on. "But if I didn't have to worry about privacy, I definitely would have gotten help sooner," she says.

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Lam's situation isn't unique. Millions of young adults have been able to stay on their family insurance plans since that provision of the Affordable Care Act took effect in 2010. But studies show that young people often hesitate to get certain types of medical care, such as mental and behavioral health care, birth control and sexual health screenings, because they don't want their parents to find out through insurance statements.

Now several states are testing ways to solve the problem, but none has a foolproof solution.

"The issue of maintaining confidentiality while a dependent is one that has existed for a long time," says Abigail English, president of the Center for Adolescent Health and the Law, a nonprofit advocacy group. "It's just receiving more attention now, because of the ACA and the increase in the number of dependents."

On NPR's Facebook page, we asked young adults to tell us about their concerns about privacy while on their parents insurance. Some said they avoided the doctor altogether, while others paid out of pocket or sought low-cost or free treatment at Planned Parenthood and community clinics.

Those who want to use their family insurance while maintaining privacy do have some options. Under the national medical privacy law, known as HIPAA, dependents have the right to ask insurance companies to redirect statements detailing sensitive medical information to a different address.

But the law implies that insurance companies are obligated to honor such requests only in cases where sharing medical information with parents would endanger the patient, English says. And it doesn't make it clear what patients have to do in order to prove that they're in danger.

Often, patients find the process of making such privacy requests too complicated or daunting, she says.

And then there's the issue of awareness. "Many young people don't even know that they have the right to do this," English says. So, many young patients avoid using their insurance to get some types of care.

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That's what Becca Holt, 23, did when she was in high school. Her parents' insurance would have covered birth control, but she didn't want them to know that she was sexually active.

"I was so nervous about them finding out. So I just went to Planned Parenthood, and I told them about my situation," she says. Holt lived in Sacramento, Calif. at the time, and Planned Parenthood helped her sign up for a statewide assistance program that helps people pay for birth control and preventative sexual health appointments.

People worried about privacy should try community clinics, says Clare Coleman, who heads National Family Planning and Reproductive Health Association.

But in the long term, it can put a strain on public funds allocated to helping those who truly lack health care, she says. "Wouldn't it be much better if patients who have insurance could just use that resource without worrying?"

A California law that took effect this year now allows people to ask insurance companies to keep sensitive health information private by submitting a single page-long form. Those who fill out the form can have their billing information sent to a different address, sent via email or made accessible online.

"It's designed to close loopholes in the existing federal laws," says Kathleen Tebb, an assistant professor at the University of California, San Francisco School of Medicine. Patients don't have to explain why they want their information kept private, and insurance companies are required to comply.

But the process isn't as simple as it seems, Tebb says. Not all insurance companies have the infrastructure in place to honor these requests.

Even when young patients manage to have insurance statements redirected, their parents can call up the insurance company ask about billing information, such as how much of their deductible has been met. Mom or Dad may wonder how their $2,000 deductible was met so quickly, and ask the kids what they've been using the family plan for.

Washington and Maryland have laws similar to the one in California. Colorado does, too, though it only applies to patients who are over the age of 18. Connecticut, Delaware and Florida offer confidentiality for treatment of sexually transmitted disease. In Massachusetts, advocates are pushing for laws that would require insurance companies to automatically withhold billing information for sensitive services.

"A number of states are struggling with this," she says. "Because it's extremely difficult to balance the privacy needs of dependents and the needs of policy holders."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Marathon Bombing Survivors Face A World That Still Feels Out Of Control

NPR Health Blog - Wed, 04/15/2015 - 3:40am
Marathon Bombing Survivors Face A World That Still Feels Out Of Control April 15, 2015 3:40 AM ET

from

Martha Bebinger Listen to the Story 3 min 46 sec  

Martha Galvis has undergone 16 surgeries on her left hand, which was injured by a bomb at the 2013 Boston Marathon.

Jesse Costa/WBUR

It's just the crumb of a muffin, but Martha Galvis must pick it up. Lips clenched, eyes narrowed, she pushes it back and forth across a slick table, then in circles.

"I struggle and struggle until," Galvis pauses, concentrating all her attention on the thumb and middle finger of her left hand. She can't get them to close around the crumb.

"I try as much as I can, and if I do it, I'm so happy — so happy," she says, giggling.

"She had a very beautiful wedding ring that was two fine bands, kind of wrapped around each other. The force of a bomb going off right next to your hand — it's kind of like a miniature hurricane."

Galvis has just finished a session of physical therapy at Brigham and Women's Faulkner Hospital, where she goes twice a week. She's learning to use a hand that doctors are still reconstructing. It's been two years since she almost lost it to the explosions at the Boston Marathon.

On April 15, 2013, Martha and her husband, Alvaro Galvis, stopped to watch the marathon from three different spots along the course; they enjoyed the race and boisterous crowd. Their last stop was near the finish line.

Watching the race was a ritual that began in the mid-1970s when the Galvises, who are both from Colombia, met in Boston. Their three children grew up celebrating the marathon as a family holiday, and Martha and Alvaro Galvis had planned to continue the annual event after retirement.

Martha and Alvaro Galvis used to travel from New Hampshire to Boston to watch the marathon every year. Both were hurt in the bombing two years ago.

Jesse Costa/WBUR

"But not anymore," says Martha, waving both hands in front of her face. "I don't feel secure to do this."

The former preschool teacher tries not to think about the moment when, just as she was reaching into a bag at her feet, a pressure cooker bomb on the ground nearby exploded, hurling nails and BBs into her left leg and hand.

"My hand," she says, "was destroyed — destroyed, it was so bad."

Dr. George Dyer, an orthopedist with Brigham and Women's Hospital, began rebuilding Martha Galvis' hand about 30 minutes after that bomb went off. Dyer was able to save everything except her ring finger.

"She had a very beautiful wedding ring that was two fine bands, kind of wrapped around each other," Dyer says. "The force of a bomb going off right next to your hand — it's kind of like a miniature hurricane. It unwrapped these fine gold bands, and then wrapped them together very tightly around her finger, and just cut it off in place."

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Dyer picked pieces of the ring out of bone and tissue and saved them for Galvis. He salvaged parts of the ring finger to replace joints and tissue missing from its companions. In Galvis' 16th surgery, Dyer took bone from her hip, where the marrow has the best potential to stimulate healing, and grafted it to a joint in her pinkie. Doctor and patient are waiting to see if she'll need further operations. Galvis calls Dyer a magician.

There were just a few serious hand injuries that day, because the deadly spray went sideways, not up. The bomb also severed nerves in Galvis' left leg. After two years of surgery and rehab Galvis says she feels worn down.

"But then, I'm thinking about when I was going to the marathon and I was cheering the people," she says, "and I say, 'Come on, keep going, keep going; one more mile.' So, I look at my hand and I say, 'Come! Come on, keep going. You can do it, this is like a marathon.' And I can feel people in Boston say, 'Yes, you can do it! Come on, keep going. Keep going.' "

"People tell me time heals. But it's a very slowly turning clock to me."

The jeweler in Boston who made Galvis' original wedding ring took the shattered, twisted pieces and molded a new band. But Galvis says that for a long time, she was afraid to put it on.

"It's silly, maybe," she says with a sheepish shrug. But she couldn't shake the worry that, "something might happen, and I could lose my hand again — the other hand."

For some survivors of the marathon bombing, the emotional and psychological scars are healing more slowly than the physical ones. Galvis pauses and reaches over to stroke her husband's back.

"People tell me time heals," says Alvaro Galvis, a health insurance salesman. "But it's a very slowly turning clock to me." He had two surgeries to repair his right leg; doctors removed from it a piece of the exploded pressure cooker — 1 inch by 2 1/2 inches. That hunk of metal became evidence in the trial of now-convicted bomber Dzhokhar Tsarnaev.

"I don't know if we are wired as human beings to be able to deal with tragedies like this," Alvaro says. "I don't know if we will ever be able to. We're trying ... we keep trying."

Alvaro Galvis struggles with flashbacks; he's jittery and anxious. He says he can't get used to the feeling that he has no control over his surroundings.

"You think about a lot of things, you know, in two years of trying to understand," he says. "That's part of the healing."

The Two-Way Boston Marathon Bombing Jury Finds Tsarnaev Guilty On All Counts

Neither Alvaro nor Martha Galvis has been able to return to work since the bombing, and they aren't sure if they ever will. They say they were getting better, before the trial. But with the verdict last week, the anniversary of the race this week and sentencing next week, they are constantly on edge. So Martha Galvis prays.

"I ask God," she says. " 'Please, in my heart, I don't want to hate him.' I don't want to hate him because it's no good for me to feel I hate him. And I ask God for him. But he has to be punished. Because he did horrible things, and he has to be punished."

Martha and Alvaro Galvis stop the interview. This is too much for them. They leave the hospital, arm in arm — supporting and protecting each other as they enter a world that they've learned they cannot control.

This story is part of NPR's reporting partnership with WBUR and Kaiser Health News.

Copyright 2015 WBUR. To see more, visit http://www.wbur.org.
Categories: NPR Blogs

No Rest For Your Sleeping Brain

NPR Health Blog - Tue, 04/14/2015 - 3:43pm
No Rest For Your Sleeping Brain April 14, 2015 3:43 PM ET Listen to the Story 2 min 41 sec  

There's new evidence that the brain's activity during sleep isn't random. And the findings could help explain why the brain consumes so much energy even when it appears to be resting.

"There is something that's going on in a very structured manner during rest and during sleep," says Stanford neurologist Dr. Josef Parvizi, "and that will, of course, require energy consumption."

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For a long time, scientists dismissed the brain's electrical activity during rest and sleep as meaningless "noise." But then studies using fMRI began to reveal patterns suggesting coordinated activity.

To take a closer look, Parvizi and a team of researchers studied three people awaiting surgery for epilepsy. These people spent several days with electrodes in their brains to help locate the source of their seizures. And that meant Parvizi's team was able to monitor the activity of small groups of brain cells in real time.

"We wanted to know exactly what's going on during rest," Parvizi says, "and whether or not it reflects what went on during the daytime when the subject was not resting."

In the study published online earlier this month in Neuron, the team first studied the volunteers while they were awake and answering simple questions like: Did you drive to work last week?

"In order to answer yes or no, you retrieve a lot of facts; you retrieve a lot of visualized memories," Parvizi says.

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As expected, the team saw activity in two widely separated brain areas known to be involved in episodic memories. And the activity was highly coordinated — suggesting the different brain regions were working together to answer the questions.

Next, the volunteers were allowed to rest and even go to sleep while the researchers continued to monitor signals from the two brain areas. And the signals from the two regions remained coordinated, as if they were still working together, Parvizi says.

"What we found," he says, "was that the same nerve cells that were activated to retrieve memories ... have a very coordinated pattern of noise."

The brain may be working to maintain the relationship between regions that have cooperated recently, and may need to again, Parvizi says. This would help explain why the brain, unlike the body, consumes a lot of energy whether or not it has a specific job to do.

"Any brain is designed in such a way that it's using a lot of energy at what we call a 'resting state,' " Parvizi says. "So it's not really a resting brain."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Is That Corporate Wellness Program Doing Your Heart Any Good?

NPR Health Blog - Tue, 04/14/2015 - 12:31pm
Is That Corporate Wellness Program Doing Your Heart Any Good? April 14, 201512:31 PM ET

Odds are your employer has a wellness program that prods you to exercise and eat healthy. But that program may not be doing all that much for your health, according to the American Heart Association, and attempts to measure the benefits of wellness programs often fail.

When it comes to improving cardiovascular health, "most of the programs appear to be falling short," says Dr. Gregg Fonarow, a professor of cardiology at the University of California, Los Angeles, and lead author of the scientific statement, which was published Monday in the journal Circulation.

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There's no consistency in the scorecards used to evaluate workplace wellness programs, the review found, and most programs don't track employees' cardiovascular health. "They focus more on processes than on the actual health that's being achieved," Fonarow told Shots.

For instance, the Centers for Disease Control's Worksite Health ScoreCard doesn't take into account employee health outcomes, the report says, while the National Business Group on Health's Wellness Impact Scorecard makes that a key metric.

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Since heart disease and stroke are the number one cause of death in the United States, that seems like a good place to start if you're trying to get workers to adopt healthy behavior.

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To that end, the heart association is launching its own set of criteria that employers can use to evaluate the worth of the wellness program they have, or of programs they're considering buying. The AHA standards are based on scientific evidence, Fonarow says, and emphasize measuring actions known to reduce risk, such as stopping smoking and being more active.

Wellness programs are a big business, estimated at $6 to $10 billion a year, so there are a lot of vendors out there trying to sell wellness programs to employers. And there's fierce debate as to whether the programs actually save companies money by making employees healthier.

The "My Life Check" calculator gives a personalized readout on heart-healthy behaviors.

via American Heart Association

The AHA also plans to offer a recognition program that employers can pay to join, but the basic measurement tools will be available for free or at nominal charge, AHA communications manager Jennifer Pratt says.

If you're wondering how this will work, the heart association already offers a free online calculator that people can use to measure their wellness efforts, so you can use it now. "My Life Check" asks simple questions like how much you weigh and how much fruit you eat in an average day, and takes about three minutes to complete.

I gave it a try. My results made me realize I haven't had my blood glucose checked in a while, and pointed out that I could stand to lose a few pounds. (I know, I know.) And it gave me an action plan with specific, reasonable advice, such as eating smaller portions and adding 15 minutes more a week of vigorous activity.

Whether employers can make workers use these sorts of evidence-based metrics is an open question, though.

Wellness programs that require employees and their spouses to get tested for cholesterol or blood glucose have come under fire, with the Equal Employment Opportunity Commission suing employers, saying that under federal law the programs must be voluntary.

But at the very least, programs like the heart association's may help people get a better sense of whether their employer's wellness program is worth the effort, or if they'd be better off doing it themselves.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Digital Tools For Health Come With 'Hope, Hype And Harm'

NPR Health Blog - Tue, 04/14/2015 - 10:51am
Digital Tools For Health Come With 'Hope, Hype And Harm' April 14, 201510:51 AM ET

Partner content from

Michelle Andrews

Dr. Robert Wachter writes that computers have crowded out eye contact between the doctor and patient, in his latest book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.

Courtesy of Susan Merrell/University of California, San Francisco

Dr. Robert Wachter has long been an advocate for patient safety and a keen observer of trends in medicine.

Years ago, Wachter coined the term "hospitalist" and predicted the rise of these doctors who specialize in caring for hospitalized patients.

Wachter, associate chairman of University of California, San Francisco's department of medicine, has a new book out: The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine's Computer Age. In it, he turns his attention to the rise of technology in health care, and the risks and rewards as we digitize everything from medical records to office visits. Here is an edited and condensed version of our recent conversation about it.

As I read your book I couldn't help thinking about the elderly. Many older people aren't tech savvy. They're intimidated by looking up information on computers and sending email to their doctors. They're also bigger health care users than many younger people. What needs to be done to help them get and stay engaged as technology advances?

It's an important question. It's not natural for them the way it is for the next generation and beyond. But most older people are at least using email and know how to surf the Web. Silicon Valley has woken up and realized this is a huge market. As consumer-oriented tech companies enter the health care field, I think they're going to design tools and technology and ways of interfacing that make it seamless for the people who need to become engaged. This will allow older patients to at least do the basic stuff, like renewing their medications, the stuff that's just incredibly annoying in the paper world.

In your book, you talk about moving away from fee-for-service payments to doctors and hospitals and toward payments based on a population of people, adjusted for their baseline health. From a patient perspective, will that change how they pay for their care? At the most basic level, could that finally mean the end of incomprehensible "explanation of benefits" insurance forms, for example?

I wish I were more hopeful. Of all the nuts we have to crack, this is the one I'm least optimistic about.

If everybody is in an accountable care organization or the like, providers get a single payment when they treat someone. But as long as they're still doing an adjustment for the relative sickness of the patients, the organization will need to account for all of the details. And I'm afraid the patient may also still see a confusing itemized bill, unless we can get to a point in which you've paid for the year and you're done.

The movement away from piecemeal payments is hopeful, and so are the digitization of health care and the entry of Silicon Valley companies with a consumer sensibility. I guess the question is: Do all of those trends — when woven together — lead to something that's more user friendly? When it comes to clinical care, I think the answer is yes. I see how we can get to a much happier place, with better care through digital medicine, in five to seven years. But the idea that you could get a simple, clear insurance bill that you pay with one click... that still feels like a moon shot to me. So maybe in 10 to 15 years.

To what extent can technology really help people comparison shop for health care? To date, we've seen that it seems to work best for procedures like colonoscopies or MRIs, where the service performed is fairly comparable. Could people really comparison shop for cancer treatment? Would we want them to?

Sure, why not? Some of this comes down to your fundamental belief in capitalism and the market. But we do have to pay some attention to fundamental differences between health care and other markets. For example, in health care, we can't accept haves and have-nots, while we readily accept this with other luxury goods. That said, I'm pretty convinced that if you create an environment where patients have the information they need to make those decisions, that the market will help them make good choices.

The area I worry about is the science. How do we really know that one doctor or hospital is better than another? Most aspects of quality measurement are not very advanced.

Another real challenge is fragmentation. If I get my colonoscopy at one place because it's the best and cheapest but it's in a different system than the one my primary care doctor is in, that's a problem if the electronic records don't talk to each other. As a patient, I've got to think about the advantage of receiving the cheapest procedure compared to the negative consequences of no one doctor having a complete view of my health.

Do you think the federal health law requirement that people have health insurance positively affects their engagement in their own health care or the health care system?

I think everybody should have health insurance. The system works better and people have better health and health care with universal insurance. And the law was the most politically feasible way to make that happen, so I support it. When people have health insurance, it creates a connection to a system that is largely mediated through a primary care doctor. To have 40 to 50 million people floating outside the system – able to access the system only episodically and when they're very ill – is crazy.

Has having insurance increased their engagement? Yes, but at a level that's pretty wimpy. Now you can see a primary care doctor to manage your blood pressure in an office visit every six months, but is that the level of engagement we should aspire to? Nowhere near it. The hope is that by having everybody part of an organized health care system, now it's in the interest of the system to have engaged patients – since that engagement should lead to fewer office visits, ER visits, and hospitalizations. But this is the sort of thing that takes years, if not decades, to develop.

What about initiatives like OpenNotes that allow patients to read their doctors' electronic notes about their care? How do they change the patient-doctor relationship?

OpenNotes illustrates the democratization of the health care system, which is going to challenge all of the system's fundamental underpinnings. Digitization is an enabler. It's changing the relationship between doctors and their patients from an extraordinarily paternalistic one to one that is more democratic. In the new world, a patient's choice is no longer just, "Do I see doctor A or B?" but "Do I even need to see a doctor at all?" OpenNotes is part of this trend.

Shots - Health News When Patients Read What Their Doctors Write

As wonderful as patient sharing access to their information is, along with new tools to self-manage and things like telemedicine that allow patients to receive care outside the traditional system, in a world of high copays you are going to see some patients making some very bad choices. In the old days, the sick patient had to go see a doctor. Now they can go to MinuteClinic. Or they can Google their symptoms. I wouldn't want to turn back the clock, but it raises the question, "When is self-management a bad choice?"

As health care finally goes digital, some people believe that it's no different than travel or banking. But no one is getting harmed by using TripAdvisor or Fidelity. I think you could argue that health care is fundamentally different.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Big Bills A Hidden Side Effect Of Cancer Treatment

NPR Health Blog - Tue, 04/14/2015 - 4:17am
Big Bills A Hidden Side Effect Of Cancer Treatment April 14, 2015 4:17 AM ET

from

Sarah Jane Tribble Listen to the Story 3 min 52 sec  

Anne Koller closes her eyes as an oncology nurse attaches a line for chemotherapy to a port in her chest. Koller typically spends three to six hours getting each treatment.

Sarah Jane Tribble/WCPN

Anne Koller was diagnosed with late-stage colon cancer in 2011 and has been fighting it since.

But it's not just the cancer she's fighting. It's the bills.

"We went from drugs that cost a few hundred dollars for a course of therapy that might be a month or six months or a year, to drugs that were costing $10,000 a month."

"Think of those old horror flicks," she says. "The swamp creature ... comes out and is kind of oozy, and it oozes over everything."

When she was able to work, Koller, who just turned 65, was in the corporate world and safely middle-class, with health insurance and plenty of savings.

At first, she was too sick to deal with the bills. They piled up.

"You start looking at these bills," Koller says, "and, as much as you know it's expensive, the shock itself is like, 'What?' "

Anne Koller was diagnosed with stage 3 colon cancer in 2011. She has been fighting cancer and the medical bills ever since.

Sarah Jane Tribble/WCPN

Her response was to begin asking her doctors about the cost of the treatments they recommended.

Middle-income patients are feeling the weight of that financial burden more than ever, says Dr. Neal Meropol, an oncologist at University Hospitals in Cleveland. He took over Koller's care a couple of years ago.

"Patients are weighing this in their calculus now," Meropol says.

High-deductible health plans and soaring drug prices are to blame, he says, and a sea change happened when a new generation of drug therapies got FDA approval for treatment in the late 1990s.

"We went from drugs that cost a few hundred dollars for a course of therapy that might be a month or six months or a year, to drugs that were costing $10,000 a month," Meropol says.

Total cost of cancer care in the U.S. is projected to reach more than $150 billion by 2020, according to the National Cancer Institute. The U.S. Centers for Disease Control and Prevention released a study last year that found that, compared with people without a cancer diagnosis, cancer survivors are less likely to work and more likely to struggle financially. Another study, out of Washington state, found that the longer a cancer patient survived, the higher the rate of bankruptcy.

University of Chicago's Dr. Jonas de Souza argues that it's time for oncologists to begin considering the financial consequences as a real side effect of cancer care.

"We talk about hair loss," de Souza says. "We talk about numbness and tingling in the hands and feet. We talk about, 'This chemotherapy will cause low blood counts.' Right. Should we also be talking about, 'Well, this chemotherapy is expensive'?"

Shots - Health News Medical Bills Linger, Long After Cancer Treatment Ends

He and Meropol are part of a growing field of researchers studying the impact of costs for cancer patients.

Koller will tell you cancer does cause financial stress.

Shots - Health News How Much Does Cancer Cost Us?

"Here's what happens," Koller says. "I was talking about that swamp thing ... but you know, OK, you go to collections. You end up with a court thing. I had been talking to the hospital, asking for help — nothing, nothing. Finally, they went to a sliding payment scale."

Her credit is ruined. So she's driving an old car. Small expenses, like an Internet connection, are out of the question. And there are other challenges.

"Socially, things change a lot," she says. "You talk to people and, if you dare, say, 'God, you know, I can't afford this,' for instance." Or, " 'Let's go out to lunch,' on the day you can eat. You ... think twice about it."

Koller says she wishes more financial information had been given earlier in her treatments. She is now using the very last of her savings to pay the bills — and, still, some are going unpaid.

This story is part of NPR's reporting partnership with WCPN and Kaiser Health News.

Copyright 2015 Cleveland Public Radio. To see more, visit http://www.wcpn.org.
Categories: NPR Blogs

I Learned The Hard Way That Concussion Isn't Just For The Young

NPR Health Blog - Mon, 04/13/2015 - 11:52am
I Learned The Hard Way That Concussion Isn't Just For The Young April 13, 201511:52 AM ET Fred Powledge Lorenzo Gritti for NPR

I think I knew what was happening even before my head bounced off the hard kitchen counter on its way to the even harder stone floor. I was rapidly losing my connection with reality. My wife, Tabitha, later estimated that I was out for 10 minutes. When I emerged from unconsciousness I heard the sirens on the street in front of the house. It seemed as if half of Tucson's fire department was streaming through the front door.

I was scared. At my age, which is old, you laugh at any childlike faith in your immortality. In this case, what brought on the unconsciousness was apparently a quick turn of my head while reaching for an onion to peel for the night's dinner, followed by the knockout blow from hitting the floor.

I was scared. At my age, which is old, you laugh at any childlike faith in your immortality.

An enormous hook and ladder and an ambulance were drawn up in front of the house, sirens winding down. The commotion was embarrassing, but it was comforting to know that my wife was in the next room, had called for help, and that 911 had responded to her call as it was supposed to.

The emergency room doctor said I had a concussion — a blow to the head that our new and improved language calls a MTBI. This scared me as much as the ambulance ride itself, since it stands for "Mild Traumatic Brain Injury."

To me, "brain injury" meant something sinister and probably permanent, something I had not seriously considered before. I foolishly had assumed that I could continue relying on my uninjured brain, along with my ultra-speedy two-finger typing, to make my living for the rest of my life.

It's not hard (if you're an emergency room physician), to spot the condition: a fall accompanied by a blow to the head. In my case, the mind's sudden descent into unconsciousness, followed by a slow return marked by a slurring of speech; inability to remember ordinary things like the words I use frequently; and a shockingly clumsy way of balancing myself and ambulating (the firemen first assessed my condition as drunkenness, but I hadn't touched a drop). My wife feared that I had suffered a stroke, but brain imaging at the hospital ruled that out.

In the past few years there's been increased attention to traumatic brain injuries in organized sports. But we old folks have the highest rates of TBI-related hospitalizations and deaths.

In the past few years there's been increased attention to traumatic brain injuries in organized sports. But we old folks have the highest rates of TBI-related hospitalizations and deaths.

The Centers for Disease Control and Prevention estimate that traumatic brain injuries in a year averaged 52,000 deaths, 275,000 hospitalizations, 1,365,000 visits to emergency rooms overall. Falls were the primary reason for the ER visits in the youngest (0-4 years) and oldest age groups (65 years and older). In those age groups, falls accounted for 72.8 percent of the children's TBI-related visits, while for those of us 65 and older, it was 81.8 percent.

There is no one-treatment-fits-all for TBI's victims, but rest is universally prescribed — during which improvement can be can be maddeningly slow. And while there is abundant research on classifying concussion in all of its forms and degrees, researchers are still working on figuring out what happens inside your head when you thump it.

Perhaps the best explanation, and one that's used often, is that a concussion produces a "cascade of events." These may include interruption of the brain's blood flow, wildly firing neurons, release of glutamate in quantities big enough to stimulate nerve cells, an increase in the levels of lactate, and imbalances in chemicals such as potassium and sodium. (Tests at the hospital revealed that my sodium level was far too low. That alone can bring about a crash.) You may be peacefully unconscious on the kitchen floor, but your head may become a maelstrom of activity—one that, because of all the chemical and physical changes that go on inside it, researchers like to call an "energy crisis."

Shots - Health News High Schools Seek A Safer Path Back From Concussion Shots - Health News Doctors Face Ethical Issues In Benching Kids With Concussions

I spent a week being observed in the hospital, followed by another week in a facility that rehabilitates people whose brains have been scrambled. There I had physical, speech and occupational therapies for three hours a day and rest for the other 21 hours. I relearned how to brush my teeth and became rather deft at piloting a wheelchair. A sign at my door warned everyone who passed by that I had a risk of falling. A therapist helped me relearn how to walk without tumbling over. Another expert watched patiently as I struggled with a large jigsaw puzzle.

Sudoku puzzles helped. Even better was a game that challenged me to perform deductive thought. As I was ending my stay at rehab, a therapist told me about a Web-based set of puzzles (paid but worth it) named Lumosity, which has become my favorite. The program, which was developed by people with PhDs after their names, combines the entertainment of playing games and solving puzzles on a computer screen. It's far more interesting than Sudoku or any of the mindless games that clog various app collections.

Despite the reams of scientific papers, conferences, website definitions and cognition-building games that are out there, recovery from concussion seems to be a crap shoot.

Now, months later, I still have not completely recovered. Writing on my computer yields an exhausting exercise in typos that I, after all these years as a reporter and book writer, have no business making. My balance and gait could be described as lurching, and I sometimes find myself forgetting the directions to my doctors' offices and the archaeology meeting we attend on Tuesday nights. (I think it's Tuesdays. Thank goodness for my cellphone calendar and the GPS on our car's dashboard.)

I don't blame my doctors and therapists for my lack of a complete recovery. Despite the reams of scientific papers, conferences, website definitions and cognition-building games that are out there, recovery from concussion seems to be a crap shoot. It must largely depend, as does recovery for most malaises, on the strength and resilience of the afflicted.

Youthfulness undoubtedly helps, but that one's out of the question for me. But how do you bring back stuff you knew so well that you've long since taken for granted? A computer password? The correct spelling of a friend's name? In my case, how to relearn my two-finger typing? How to drive to a favorite restaurant? On one occasion, my own phone number?

Now, months later, I still have not completely recovered. Writing on my computer yields an exhausting exercise in typos that I, after all these years as a reporter and book writer, have no business making.

I'm heartened by the story of George Clooney, who suffered a concussion while filming Syriana in 2005. (He was tied to a chair, and someone bumped over the chair.) Even he had to struggle to regain memory, and resorted to writing down his lines on random bits of paper. He later won an Academy Award.

It's easy to start feeling sorry for yourself, especially when your thinking is so heavily contaminated with typos. I do a lot of reflecting about the concussion, and when I start to get despondent, I recall the experience of our next-door neighbor. She's a young and energetic woman, full of vitality and good humor. After I returned home from the hospitals, we gossiped over the fence about our experiences in the scary world of brain damage. "I crashed my bicycle 11 years ago," she told me, "and I still have trouble remembering things."

Fred Powledge is the author of scores of articles and 17 books, six of them for young readers. He lives in Tucson with his wife, who is a science writer.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Why Some Doctors Hesitate To Screen Smokers For Lung Cancer

NPR Health Blog - Mon, 04/13/2015 - 3:30am
Why Some Doctors Hesitate To Screen Smokers For Lung Cancer April 13, 2015 3:30 AM ET Listen to the Story 4 min 32 sec  

This spiral CT image of the chest shows a large malignant mass (purple) in one lung. A conventional chest X-ray could have missed this tumor, radiologists say.

Medical Body Scans/Science Source

In February, Medicare announced that it would pay for an annual lung cancer screening test for certain long-term smokers. Medicare recipients between the ages of 55 and 77 who have smoked the equivalent of a pack a day for 30 years are now eligible for the annual test, known as a spiral CT scan.

Medicare's decision was partly a response to a 2011 study showing that screenings with the technique could reduce lung cancer deaths by 20 percent.

Shots - Health News Panel Urges Lung Cancer Screening For Millions Of Americans

That translates into thousands of lives each year, says Dr. Claudia Henschke, a radiologist who heads the lung and cancer screening program at New York's Mount Sinai Medical Center.

"It's a tremendous step forward," she says, primarily because lung cancer is such a big killer. The disease claims more than 150,000 lives in the U.S. each year, more than the next three cancers — breast, prostate and colon cancers — combined.

But as more and more people are getting screened for lung cancer, other doctors worry the test is doing more harm than good.

"It's the two-edged sword," says Dr. H. Gilbert Welch, a professor of medicine and health policy at the Geisel School of Medicine at Dartmouth. "The scans can see very early cancers," Welch says, "but [can also] find cancers that were never going to matter."

Shots - Health News Analysis Finds Lung Cancer Screening Worthwhile For Longtime Smokers

That's because some cancers grow slowly and never become dangerous, he says. Welch describes this phenomenon in his new book, Less Medicine, More Health: 7 Assumptions That Drive Too Much Care.

Welch says spiral CT scans also detect a lot of things that are not cancerous. Nearly a quarter of the 2011 study's participants had multiple tests that showed abnormal growths in the lungs that turned out not to be cancer. These false-positive tests led to more follow-up testing, including risky procedures like a biopsy, which inserts a needle into the lung.

"Not surprisingly," Welch says, "sometimes that creates problems like causing someone's lung to collapse."

Welch is not claiming that that 2011 study, known as the National Lung Screening Trial, was bad science. A panel of independent experts called the U.S. Preventive Services Task Force reviewed the data and determined that, overall, using the CT screening to find lung cancer does more good than harm.

Dr. Andy Lazris, an internist in Columbia, Md., isn't enthusiastic about using spiral CT scans to look for lung cancer in his patients. "Not many people are going to benefit," he says.

Anders Kelto/NPR

But Welch is concerned that the results of the study will not be replicated in the real world. In the study, he says, the radiologists were highly skilled at detecting lung cancer from a CT scan. The doctors were cautious, he says, and went to great lengths to avoid invasive tests like biopsies. Plus, the researchers clearly explained potential risks to patients, including the high rate of false positives.

In everyday medical settings, Welch says, that won't always be the case.

"There are real reasons to be concerned that the harmful effects of the screening might actually be greater in practice," he says. In other words, the net benefit of CT screening might not exist in the real world.

Dr. Andy Lazris is an internist and primary care physician in Columbia, Md., and says his practice includes a lot of older smokers. He has looked carefully at the data and is not enthusiastic about using CT scans to look for lung cancer in his patients, most of whom are over 55.

"Not many people are going to benefit," he says. "A lot of people are going to get these false alarms and a lot of people are going to get excessive testing and potential harm."

To help his patients understand the odds, he shows them a picture of a theater seating diagram.

"Out of a thousand seats in the theater, there are 3 1/2 blackened seats, which are barely visible," he says, pointing at the diagram shown on the left. "These are lung cancer deaths averted with spiral CT.

(Left) Dr. Andy Lazris' analogy of the number of lung cancer deaths averted with annual spiral CT scans (black rectangles), compared to the total number of scans done. (Right) The black rectangles, or "filled seats," represent the number of scanned patients who would receive false-positive test results.

Courtesy of Andrew Lazris and Erik Rifkin: Interpreting Health Benefits And Risks

Then Lazris turns the page to another diagram, shown here on the right.

"This is a crowded theater," he says. "Out of a thousand people, 233 people will have persistent false positives."

These false-positive results lead to further tests, he says, which means more exposure to potentially dangerous radiation and the risk of complications. There can be additional costs, adding to the stress of thinking you might have cancer.

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Lazris says he shows the theater diagrams to many of his patients and gets a wide range of responses. Some patients, he says, point at one of the three blackened seats and say, " 'That's probably me. I'm not taking any chances, I'm getting this test.' "

"Other people," he says, "will see [the same diagram] and will say, 'Are you kidding me? I'm not going for that; that's not worth it.'"

But in either scenario, Lazris says, he has done his job — he has helped his patients understand the odds and then let them make the choice.

Medical centers that screen Medicare patients are required to report their results to the government. Officials will be assessing each center's performance and tracking patient outcomes to determine whether screening with spiral CT — when expanded to a much larger scale — is doing more harm than good.

Meanwhile, Dr. Henschke suggests that patients who are considering getting the screening remember a couple of things.

First, they should discuss the benefits and risks with a primary care physician, she says. Medicare requires doctors to meet with patients before writing a referral, so patients should be sure they take advantage of this opportunity.

Also, Henschke says, patients should get the spiral CT done at a facility that has plenty of experience in screening people for lung cancer — "a place where you have a team of people who are aware of what early lung cancer looks like."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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The Hidden Cost Of Mammograms: More Testing And Overtreatment

NPR Health Blog - Mon, 04/13/2015 - 3:27am
The Hidden Cost Of Mammograms: More Testing And Overtreatment April 13, 2015 3:27 AM ET Listen to the Story 2 min 10 sec  

There's no question mammograms can save lives by detecting breast cancer early. But they can also result in unnecessary testing and treatment that can be alarming and costly.

In fact, each year the U.S. spends $4 billion on follow-up tests and treatments that result from inaccurate mammograms, scientists report in the current issue of Health Affairs.

Shots - Health News How Much Can Women Trust That Breast Cancer Biopsy?

That's a "stunning number," says the study's lead author, Dr. Kenneth Mandl, at Harvard Medical School's Center for Biomedical Informatics.

Mandl and a colleague analyzed the insurance records of more than 700,000 women from 2011 to 2013. The women were between the ages of 40 and 59, and they all had routine mammograms to screen for breast cancer during that time period.

About 11 percent of the women had "suspicious" mammograms and were subjected to further testing, including repeat mammograms, ultrasounds and needle biopsies. For nearly all these women — 98.6 percent — cancer was not confirmed in further testing.

Shots - Health News 3-D Mammography Finds More Tumors, But Questions Remain

When Mandl projects this percentage of false alarms to the entire female population over age 40, he estimates that the U.S. spends $2.8 billion dollars each year on follow-up tests for suspicious results that turn out not to be cancer.

And even when cancer is detected, some of those tumors might be of low-risk to the patient — slow-growing and not likely to become invasive or life-threatening. But once suspicions are raised, Mandl says, overtreatment is often the result. "Overtreatment is bad," he says. "That's mastectomy, chemotherapy, radiation, in women who may not have needed any medical treatment at all."

Shots - Health News When Treating Abnormal Breast Cells, Sometimes Less Is More

For example, patients diagnosed with ductal carcinoma in situ can face radiation, chemotherapy and even mastectomy despite the fact that the cancer is noninvasive.

Mandl estimates that the cost of overtreatment adds up to $1.2 billion each year, resulting in a grand total of $4 billion in unnecessary spending annually.

And it's not just the financial cost that's a problem. When a woman receives a suspicious mammogram result, it often creates psychological stress and anxiety, Mandl says.

Still, some researchers have issues with Mandl's findings. Dr. Richard Wender, of the American Cancer Society, says the study overestimates the cost of unnecessary testing and incorrect diagnoses. And he says it fails to consider the proven benefits of annual mammograms.

Shots - Health News Why Younger Women Could Benefit From Mammograms After All

"Mammograms are the most effective way we have to find breast cancer before anybody can feel it, before you're aware of it," Wender says.

He points to studies showing that mammograms reduce the risk of dying from breast cancer by 20 percent. "So whenever we're doing decision making, either as policy makers or just between one woman and her doctors, it's critical to look at ... benefits as well as downsides," he says.

The American Cancer Society recommends yearly mammograms for women starting at age 40. However, the U.S. Preventive Services Task Force recommends that screenings start later, at age 50. That's because younger women, between 40 and 49, are more likely to receive false-positive results.

Harvard's Mandl would like to reduce the number of screening mammograms even further. He suggests that screening be based on a woman's overall risk factors for breast cancer, including family history, obesity and breast density, as well as age.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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