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The Private Practice Oncologist, a Vanishing Breed

November 24, 2014

chemoIn the northwest we are lucky indeed to be home to the Seattle Cancer Care Alliance; the SCCA is a world class center that unites doctors from Fred Hutchinson Research Center, UW Medicine, and Seattle Children’s Hospital. But what if someone wanted to seek treatment or even just an opinion elsewhere in Seattle? As it turns out, there’s only one independent oncology group in Western Washington now.

It’s not just in the Northwest where independent oncology groups are disappearing. The Community Oncology Alliance, an advocacy group for independent practices, said that since 2008, 544 of 1,447 such groups were purchased by or entered contractual relationships with hospitals; another 313 closed and 395 reported they were in tough financial straits.

This is tied to reimbursement schedules for chemotherapy drugs: cancer centers, as opposed to private groups, participate in a federal program that lets them purchase these drugs for about half what private practice doctors pay. When a doctor is affiliated with a hospital or research center, though, patients end up paying, out of pocket, an average $134 more per dose for the most commonly used cancer drugs, according to a report by IMS Health, a health care information company. So while cancer centers pay less, they charge more.

Thus far health care economists say they have little data on how the costs and profits from selling chemotherapy drugs are affecting patient care. The cost of chemotherapy drugs has increased tremendously in the past decade, however, resulting in more out-of-pocket expenses for those even with comprehensive insurance coverage and tremendous expenses for those without coverage. With drug manufacturers promoting individual drugs through aggressive marketing techniques (as an example in this New York Times article, Celgene, in a recent email about its drug Abraxane, told one doctor who had bought 50 vials that he could get a rebate of $647.51 by buying 68 vials. If he bought 175 vials he’d get $1,831.93), the effects of this combined set of circumstances — increased cost of drugs, tiered reimbursements, fewer private practice alternatives — the best treatment options may not be the prevailing care options for some cancer patients.

While individual oncologists deny choosing treatments that provide them with the greatest profit, Dr. Kanti Rai, a cancer specialist at North Shore-Long Island Jewish Cancer Center, said it would be foolish to believe financial considerations never influence doctors’ choices of drugs. “Sometimes hidden in such choices — and many times not so hidden — are considerations of what also might be financially more profitable,” he said.

Dr. Peter Eisenberg, in private practice in Marin County in Northern California, summed it up: “The disgrace is that we have to treat people differently depending on how much money they’ve got.”

80,000,000 Bacteria Per Kiss?

November 21, 2014

kissingA 10-second “intimate kiss” can transfer a whopping 80,000,000 bacteria from one mouth to another, according to a new report in the journal Microbiome. The related study was completed by Dutch researchers at Artis Royal Zoo in Amsterdam and involved 21 couples.

The more often a couple kissed, the more similar the bacteria in their saliva samples, with the researchers concluding that couples needed to kiss at least nine times a day to achieve notably lower bacteria levels. The men said they kissed their partners an average of 10 times a day, while the women recalled kissing only five times a day. The researchers concluded that the men were most likely exaggerating the frequency of their romantic encounters. Read more…

 

Addressing the Obesity/Cancer Link: What Will We Learn From China?

November 14, 2014

chinese obesityIt has long been known that excess weight is a major health risk, but until recently cancer hadn’t been a major part of the obesity/health discussion. A recent British study of 5.24 million people, however, looked at the occurrence of 22 different cancers and their association with body mass index (BMI), a measure of weight/body size and type.

The study concluded that when adjusted for factors like age and smoking, a higher BMI was associated with a large increase in risk of cancers of the uterus, kidney, gallbladder, and liver, and smaller risk increases for at least six other types of cancer.

What’s Your Fitness Age?

November 11, 2014

fitness ageIt’s not news that longevity is tied in part of how fit we are. What is new is a study from researchers at the Norwegian University of Science and Technology which examined data from more than 55,000 Norwegian adults who had completed extensive health questionnaires beginning in the 1980s. The scientists used the volunteers’ answers to estimate each person’s VO2max and “fitness age.”

According to the study’s authors, the results suggest that fitness age may predict a person’s risk of early death better than some traditional risk factors like being overweight, having high cholesterol levels or blood pressure, and smoking. There’s also a link directly to a short test to find your own fitness age, with exercise suggestions.

Thankfully, fitness age can be altered, said Ulrik Wisloff, professor at the K.G. Jebsen Center for Exercise in Medicine at The Norwegian University of Science and Technology, who led the study. His advice if your fitness age exceeds your chronological years or is not as low as you would like? “Just exercise.”

Medicine still requires the vignette

November 7, 2014
Image from ASR Analytics

Image from ASR Analytics

In an era of systematic clinical research, medicine still requires the vignette, as explored in this opinion piece. The multiple comments are interesting as well, many with strong opinions which provide illumination into why patient stories are (still) so important and how they fit with a sound scientific approach to better treatment:

In addition to reminding us of the real and human part of practicing medicine, stories are great hypothesis generators. Evidence-based medicine is important, but no real evidence can be generated until a testable hypothesis is created. This is where vignettes play an important role. When we see an outcome, especially if it’s unexpected, it forces us to ask questions, which in turn lead to hypotheses.

Your Brain’s Silent Killers?

November 3, 2014

gluten freeby Laura McFarland, Communications Director

Turns out my mother might not be so unusual after all. Or at least in one particular way: she’s gluten intolerant, but not celiac. For years she ate crackers to settle her stomach; then she learned that it was the crackers that were upsetting her stomach.

She is joined by nearly 20 million other Americans who regularly experience distress after eating products that contain gluten. About 1% of the population has celiac disease (an autoimmune disorder that can occur in genetically predisposed people where the ingestion of gluten leads to damage in the small intestine). Currently, however, according to this fascinating article in The New Yorker, about a third of American adults, a number well beyond even this 20 million,  say that they are trying to eliminate gluten from their diets.

Given that humans have been eating wheat for about ten thousand years, what’s going on that would suddenly make the numbers of those who experience intolerance increase? The article explores multiple possibilities — a change in wheat’s genetic composition, the modern diet, changes in the bacteria which help us digest food, intolerance of a specific group of carbohydrates (FODMAPs), too much vital wheat gluten — and provides examples of studies.

Multiple opinions are noted, from David Perlmutter, a neurologist and the author of one of the gluten-free movement’s foundational texts, “Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar — Your Brain’s Silent Killers,” writes “Gluten sensitivity represents one of the greatest and most under-recognized health threats to humanity.’’ Given that 20% of the world’s calories, not to mention the basis for multiple economies, come from wheat, that’s a fairly daunting concept to grapple with.

Then there’s research by Joseph A. Murray, a professor of medicine at the Mayo Clinic and the president of the North American Society for the Study of Celiac Disease. Said Murray, “Everyone is trying to figure out what is going on, but nobody in medicine, at least not in my field, thinks this adds up to anything like the number of people who say they feel better when they take gluten out of their diet. It’s hard to put a number on these things, but I would have to say that at least seventy per cent of it is hype and desire. There is just nothing obviously related to gluten that is wrong with most of these people.’’

So which is the more accurate perception? Perhaps understanding what’s really being removed from one’s diet when they try to give up gluten. As author Michael Specter suggests, “The initial appeal, and potential success, of a gluten-free diet is not hard to understand, particularly for people with genuine stomach ailments. Cutting back on foods that contain gluten often helps people reduce their consumption of refined carbohydrates, bread, beer, and other highly caloric foods. When followed carefully, those restrictions help people lose weight, particularly if they substitute foods like quinoa and lentils for the starches they had been eating. But eliminating gluten is complicated, inconvenient, and costly, and data suggest that most people don’t do it for long. The diet can also be unhealthy.”

Gotten Your Flu Shot Yet?

October 28, 2014

flu shotSome good news on the vaccination front: the World Health Organization (WHO) welcomes the approval by Swissmedic, the Swiss regulatory authority for therapeutic products, for a trial with an experimental Ebola vaccine at the Lausanne University Hospital. This marks the latest step towards bringing safe and effective Ebola vaccines for testing and implementation as quickly as possible. The goal is to produce millions of doses of two experimental Ebola vaccines by the end of 2015.

That’s incredible news; as of last Friday the U.S. Center for Disease Control was reporting a total of 10,141 report cases worldwide, with 5,692 confirmed by testing and 4,922 deaths so far.

Closer to home, there are plenty of alarming health situations to worry about over which we have much more control. During the 2013-2014 flu season, for instance, only 46% of Americans received their flu shot, even though it kills about 3,000 people in this country in a good year, nearly 50,000 in a bad one. Flu shots don’t provide immunization against every strain of flu, but they greatly decrease the likelihood of contracting the flu and the severity of the flu should one become ill. So, as New York Times op ed piece asks:

Do me a favor. Turn away from the ceaseless media coverage of Ebola in Texas — the interviews with the Dallas nurse’s neighbors, the hand-wringing over her pooch, the instructions on protective medical gear — and answer this: Have you had your flu shot? Are you planning on one?

 

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