Friday, December 25, 2009

A Dose of Christmas Humbug

Today's Boston Globe reads, "Health Win in Hand." You can almost feel the exclamation point coming off the page. It follows with the caution, "Hurdles Ahead." Noting that the healthcare bill still faces the challenge of reconciling the two substantively different bills passed by both houses of Congress, not to mention Constitutional challenges and whatever other dirty tricks the Senate Republicans can muster between now and the passage of the reconciled bill, the Globe has a side article usefully informing its readers that this bill may still not become law because the coalition supporting the bill is so fragile it may come apart during the usually perfunctory reconciliation phase. That said, assuming that no 11th hour roadblocks are raised, universal health care is going to become law in the US. Our President has put a happy face on things, saying he got "95 percent of what I want."

On this Christmas Day, allow me to honor a ghost of Christmas past (and doing so as a virtually-atheist Jew, no less) by saying...HUMBUG!

Paul Krugman--not normally a man predisposed to cheery pronouncements just for the sake of feeling good--writes in the NYT that the bill, despite a number of flaws, really is a major accomplishment and will lead to improvement in the lives of Americans in the coming years. But he does provide an analysis of why so many people are so unhappy:

So why are so many people complaining? First, there’s the crazy right, the tea party and death panel people — a lunatic fringe that is no longer a fringe but has moved into the heart of the Republican Party. In the past, there was a general understanding, a sort of implicit clause in the rules of American politics, that major parties would at least pretend to distance themselves from irrational extremists. But those rules are no longer operative. No, Virginia, at this point there is no sanity clause...Finally, there has been opposition from some progressives who are unhappy with the bill’s limitations. Some would settle for nothing less than a full, Medicare-type, single-payer system. Others had their hearts set on the creation of a public option to compete with private insurers. And there are complaints that the subsidies are inadequate, that many families will still have trouble paying for medical care...Unlike the tea partiers and the humbuggers, disappointed progressives have valid complaints. But those complaints don’t add up to a reason to reject the bill. Yes, it’s a hackneyed phrase, but politics is the art of the possible. [my emphasis]

So what's a disappointed progressive to do?

Let me go out on a limb here--very, very far out on a limb--and suggest that maybe the nutso wing of the Republican party (which is now the de-facto leadership of the Republican party) has the right strategy, and maybe it is time for progressives to take a page from their playbook. The phrase that's been bandied about over the past year in relation to the tea-partiers is that they demand of their representatives that they "pass a political litmus test" demonstrating a level of ideological purity. We saw this most clearly in evidence in the New York 23rd Congressional race this November, where so-called "liberal" Republican Dede Scozzafava was abandoned by the Republican base in favor of 3rd-party candidate Douglas Hoffman, allowing Democrat Bill Owens to win in an overwhelmingly Republican district. The conventional wisdom of that election was that the far right had become so crazy that they would rather be out of power than have an electable candidate who wasn't absolutely ideologically pure. My own sense is that the Tea-Party choice, Hoffman, very nearly won the election (he lost by just over 3,000 votes out of 140,000 cast), and almost certainly would have won had he had an additional few months to gain momentum.

So while the strategy of demanding ideological purity failed the far right on the political equivalent of a broken play, I suspect it will pay long-term dividends. Even in marginal districts, potential Republican party candidates are going to be very careful not to run afoul of this very determined, apparently reasonably well-organized group. Yes, in the short run they may have some setbacks as they had in the NY 23rd. But next year I am willing to bet that Owens will be out and he will be replaced by someone approved of by "the base," maybe Hoffman himself.

Might it not be time to demand this from Democrats? Particularly Democrats running for Senate seats? Or even President of the United States? I am not suggesting that an ideological litmus test need to be applied to every single issue that faces us. But demanding support for the Public Option (which, after all, was the compromise position that progressives had decided to live with instead of a Medicare-For-All, single-payer system that would represent real change) would have been a starting point.

Anyway, perhaps Krugman is right and the reasons to be unhappy with the bill are not reasons enough to walk away from it. But I do note that Krugman's view is not universal among progressives, and I'm quite sympathetic to their viewpoint. Here is a great summary in an editorial for CNN online by the mightily courageous Congressional representative from the NY 28th district, Louise Slaughter. She has one line, nicely summarizing the critical difference between the House and Senate versions of the health care bill, that captures it all for me: "I do not want to subsidize the private insurance market; the whole point of creating a government option is to bring prices down." I have yet to hear anything from the leadership of the Democratic party that lucid. Perhaps it is time to think about withholding our support from leaders who do not speak or act as clearly as Congresswoman Slaughter.

Thursday, December 17, 2009

Do NOT Go Spelunking in Sub-Saharan Africa! (Plus Mammogram Stuff.)


PS--As a follow-up to the news on CT scans and people misoverestimating its dangers (as Bush 43 might say), a good comparison can be found in the recent brouhaha about the US Preventive Services Task Force revised recommendations about when women should obtain mammograms. In mid-November, the USPTS rolled back the recommendations for annual mammograms for women under 50, and for women over 50, they recommended mammograms every other year.

There was a firestorm, with outraged women calling up congressfolk and other government people howling about how women's lives are worth less than men's. Even prominent academics took to the airwaves and cyberspace to pile on, as this piece by the University of Pennsylvania's Center for Bioethics Arthur Caplan demonstrates. "Screening is what responsible and health-conscious women do to take control of their bodies and prevent disease," Caplan wrote. Those are commendable and powerful virtues, and...more compelling than a pile of bland data...there is no reason to doubt the accuracy of the scientists' findings...but there is every reason to doubt that the numbers they compiled will be sufficient to overturn a medical practice that carries so much ethical weight for women." [my emphasis]

Ladies and gentlemen, a nominee for Most Cowardly Writing By An Academic For 2009! That little pile of bland data suggested that, whatever "ethical weight" pre-50 mammograms may have for women, it would lead to unnecessary amounts of radiation, agonizing trials for women awaiting biopsies of tissue that didn't need to be biopsied, and, in some cases, completely useless mastectomies. Could a guy like Caplan maybe have considered it his responsibility to use his status as Big Time Academic to try to help explain this data, and give it the proper context it deserved because the data indicate a better way to treat women? He will have to answer for that. In the meantime, a nice counter-example can be found in this NYT op-ed by the very awesome mathematician John Allen Paulos, who tried his best to explain to women the potential benefits of the USPTS recs, at least in terms of the mathematics of the probability of a "positive" mammogram being a "false-positive" due to the relatively low prevalence of breast cancer in the 40-50 group.

The US Senate, which has shown remarkable ineptitude thus far in getting even the most modest health care bill passed, rushed to include an amendment to cover the mammograms its own USPTS no longer recommends...pleasing wild-eyed constituents and providing just the kind of unnecessary radiation discussed in the cat scan studies that so freaked people out! (Though yes, a mammogram has far less radiation than a standard cat scan.)

So I say of this: you can't have it both ways!

Perhaps the USPTS might have been more media-savvy about announcing their new recs, and perhaps they might have more shrewdly thought out how to get this information out. But the notion--which seems to have been uncritically bandied about by people in positions of authority in both government and academia--that this is part of science's ongoing war against women is not merely short-sighted, it may well harm women! This may be the final irony of what medical historians in the coming years might call the "Radiation Flap of 2009." Too much radiation from CTs, not enough radiation for mammograms...and not enough people with a bully pulpit brave enough to try to help show people the way.

I do want to note that the issue gets stickier when one considers African-American women under 50. Please--for the few people who read this blog, pass this information on to African-American women! They are at higher risk of having breast cancer before age 50 compared to white women. The problem is that it's not fully clear that earlier mammography will put a dent in the excess mortality rate, because the most lethal types of breast cancer, and the kind that AA women are more likely to have, grow more rapidly than the kind of cancers that mammograms are good at detecting and thus "pop up" in between screens due to their rapid growth and can be found simply by feeling them. A good discussion of the problem can be found here at the Science-Based Medicine blog. In short, African-American women aged 40-50 need to take special care and not simply take the USPTS recs at face value. Not that anyone is, but still.

Tuesday, December 15, 2009

Cat Scans and Cancer

The recent news about the study indicating that about 30,000 extra cases of cancer may be caused by CT scans (audio version from WBUR here, silly shallow TV version below) didn't surprise me much. I have yet to read the study, so I cannot speak to its methods and whether I agree with its conclusions, but it certainly sounds plausible. After all, a CT scan provides a relatively large dose of radiation...I was told by a radiologist during my residency to think of it as the equivalent of 300 x-rays, although according to the news stories this number is at the high end of the estimate, noting that most scans are equivalent to about 100 x-rays. The sicker you are, the more likely you are to get more than one cat scan; some patients that I admit have had dozens of cat scans in a time span of only a few years. Because dividing cells are exquisitely sensitive to radiation and can more easily become cancerous, a few CT scans won't make much difference if the patient is 60 or 70 because most of the cells in their bodies don't actively replicate. But in a 30 year-old--or even one cat scan in a child, whose cells will divide multiple times over the span of their life--this dose of radiation is not without its risks.

So like I said, not a major surprise. Also not surprising is that a good number of these scans were unnecessary: the link above to Toronto's Globe and Mail is useful because it approaches the study from a Canadian perspective, and helpfully points out that Canadian MDs order about half the number of cat scans than their American counterparts, and even then Canadian health experts believe that about a third of those are unnecessary. From a systems perspective on how docs utilize these tests, it's a problem.

How big a problem is an open question. I don't want to sound like an apologist for radiation or to soft-peddle the serious problems raised by this study, but there has been a fair amount of context missing from the news stories and a not-insubstantial amount of fear-mongering to boot. Take a listen to WBUR's Robin Young as she practically jumps out of her seat from fear of getting cancer by just talking about the subject with radiologist Donald Frush of Duke:

"Well, let's get to some of these scary and startling statistics. We understand that some of the highest doses of radiation are routinely used for coronary angiography [to look for blocked arteries in the heart]...the Los Angeles Times writes that according to the [study]...1 in 270 women and 1 in 600 men, at the age of forty, just one [scan], might be at risk to develop cancer as a result. That's a pretty startling conclusion." [my emphasis]

Scary, startling...and Dr. Frush to his great credit gave some critical context to the statistic: that this looks at people who are getting very high levels of radiation, that not all experts agree with the calculations and that the risk may in fact be lower, and most importantly that it ignores the benefit derived from the patients who receive an accurate diagnosis as a result of such a test.

For instance: I admitted a patient recently and was told by the ER physician that "this guy's got community acquired pneumonia, couldn't hack it as an outpatient, he just needs pain control." The patient, a relatively young man in his 30s, had been feeling lousy for a few days and saw his primary care doc, who ordered some blood tests and a standard, low-radiation dose chest x-ray, which I could see in the ER clearly showed an "infiltrate"--a hazy spot on the film that certainly looked just like pneumonia. His blood test showed a high white count indicating an infection, and so before I even saw the patient it seemed like the diagnosis was gift-wrapped: game, set, match. Give the guy antibiotics and some morphine and move on to the next patient.

Only problem was that as soon as I started talking to the patient things weren't making sense in the nice, clear way the labs and film suggested. I found out that he had had these symptoms a few times in the last six months; the symptoms included coughing up blood and night sweats. Can regular old pneumonia cause someone to have night sweats and cough up blood? Sure, but in an otherwise healthy guy in his 30s who just recovered from a similar bout two months ago? That was weird. I mulled it over and after talking about other things like recent travel, his family background, and his job, I realized he could have one of many different things and "community acquired pneumonia" was now about the fifth or sixth most-likely diagnosis. I was worried that he might have had undiagnosed HIV, or tuberculosis, or a pulmonary embolism (a "PE," which is a blood clot in the lungs), or lymphoma, or even lung a few other more zebra-like diagnoses. To rule out each of these things would require different tests, but the first place to start was by getting a cat scan to rule out cancer and that blood clot. An hour later, I had my answer: he had several PEs in his lungs. The treatment he needed was blood thinners, not antibiotics. It wouldn't be too melodramatic to suggest that the cat scan--which delivered that radiation that so spooked Robin Young of WBUR--may well have saved his life.

It's that kind of nuance that requires emphasis every time one of these studies comes out. Indeed, the study estimated that unnecessary radiation from cat scans accounted for only 2 percent of all cancers. Will that be taken into account by every current cancer patient who has undergone a CT scan when they hear the story, or will they assume that their cancer was without doubt cause by a careless doc or hospital or CT scan manufacturer? Will she be like Connie Barton, the woman recently featured in the Sunday NYT who believes that her breast cancer diagnosis was, without question, due to the hormone replacement therapy that was prescribed by her doctor and made by Wyeth, Inc.? At least in the Barton case I'm sympathetic: Wyeth, as the Times notes, "oversold the benefits of menopausal hormones and failed to properly warn of [its] risks." But docs aren't cashing in on thousands of useless tests: if anything, the problem is often the reverse based on my experience, namely that we order tests defensively, fearing that if we don't get a cat scan for something we're pretty confident doesn't require one, we could find ourselves in court having to defend not ordering the test sometime down the line.

In other news, Season's Greetings! In the Rubin household this means "Happy Hanukkah." Billy notes this truly weird article in the Times about how the Very Mormon Senator Orrin Hatch (R) of Utah wrote a little Hanukkah jingle and even did a little bopping (ahem, the musical variety) in the studio. Quoth the Senator, "Anything I can do for the Jewish people, I will do." All Billy can say is: please don't do much! (Though thanks for the sentiment.) And, of course, Billy thanks the Lord that his last name is Rubin and not, say, Hatch. Hat Tip to the Professor of Rhode Island.

Wednesday, December 2, 2009

Flu Thoughts

Good news, team: this flu season's about to come to an end. Bad news is that the regular flu season is just getting underway.

It is hard to underscore just how much this virus tore through the population. The CDC reports higher-than-normal medical visits for influenza-like symptoms in every region of the country--a total of 51 of 54 epidemiologic jurisdictions. Now it doesn't tell you the total number of cases, which at this point could only be made with a guess as most cases are identified "clinically" and aren't even reported, much less confirmed. There are just too many cases to allow for that kind of precise measurement. However, the CDC's best guess is that, by the end of the epidemic, about 22 million Americans will have been infected. That's simply an awesome number of infections.

If you have gotten the flu thus far, it's overwhelmingly likely that you got the novel H1N1 virus. The CDC data indicates that only four out of nearly 2,500 strains are "seasonal" strains. ("Strains" are the molecular sub-type of the virus...think of different colors and years of Toyota Priuses, with one or two Camrys thrown in, and you've got a rough idea of strain differences.) And some further good news is that these strains remain almost universally sensitive to oseltamivir (Tamiflu). Even better is that this virus so far hasn't become really deadly. Shown below is the graph displaying pneumonia and influenza mortality (link above) and, except for a recent blip, the mortality is well within the expected level during
nearly all of the "Swine Flu" epidemic. The CDC estimates are for a total of 3900 deaths (540 of those occurring in people less than 18 years of age), which is considerably less than the average annual influenza mortality, which tops off at about 40,000. We owe our good fortune to the fact that this flu strain wasn't particularly virulent and thus far hasn't shown any predilection for mutating into a deadlier strain. There was some news coming out of Norway that there was a more virulent strain that had been recovered in two patients who had died and a third who had been critically ill, but subsequent samples from other patients haven't shown the same molecular signature. So, all in all, hard to say what's going on there.

I've heard a lot of concerns from family and friends over the past several months about the safety of the flu vaccines. An amazing 72 percent of Americans are either very or somewhat concerned about the safety of the Swine Flu vaccine. Granted, it has been been confusing, given frequently changing recommendations from the CDC, the shortage of the vaccine, and the generally confusing issue that there are separate vaccines for the seasonal flu strains and the Swine Flu strain. Still, at least two points need to be kept in mind: first is that the technology used to make the flu vaccine hasn't changed in decades; the vaccine for the novel strain is no more "novel" than that of the seasonal strains, it's just that the strain of virus being grown in chick eggs--yes, that's how it's done--is different. The process of manufacture, however, is totally the same. The second point is that it's very safe. Keep in mind that there is the issue of "background noise" when you give out this many vaccinations: if you just watch 10 million people over the span of six weeks, nearly 17,000 women will have miscarriages, about 20 of them will come down with Guillan-Barre Syndrome (a potentially life-threatening condition sometimes associated with vaccines), and half a dozen will experience the joys of sudden death. So that means that you'd expect to see these kinds of numbers following a mass vaccination campaign. If you're trying to understand why you got Guillan-Barre solely from the perspective that you were vaccinated the week before, you can't really know just from your own experience whether the vaccine was the cause; you have to look at the incidence throughout the population. (The failure to grasp this point is what makes the anti-vaccine crowd so exasperating. Statistically, when you give millions of vaccine doses it's bound to happen that some kid is going to get sick after getting the shot...because the kid was going to get sick anyway!) Of the nearly 34 million doses of the Swine Flu vaccine given so far, there have been only 84 reported adverse events associated with the vaccine, including 6 deaths and 4 cases of GBS. That's a pretty good record.

If one must be in the vaccinophobic crowd, then at least pick the right thing over which to have an irrational fear. Like I said, the vaccine that you may or may not have gotten for your kid due to shortages is just an old-fashioned vaccine. You want truly different? The FDA just met and decided against a flu vaccine "manufactured" using caterpillars. The Protein Sciences Corporation in Meridien, CT had their application rejected on a 6-5 vote mainly because the data at this point in time are insufficient. But you can tell by the vote that it's close. Advantages of making flu vaccines in caterpillars? One, people who have egg allergies can be vaccinated, and two, the company claims that because the virus grows faster in caterpillars than in chick embryos it could ramp up production much quicker than in the traditional manner, no small consideration given the profound shortages of vaccine stocks this time around. (And keep in mind that it's still likely an irrational fear.)

My own sense of the mild hysteria surrounding the flu vaccine? An indicator of the extent to which Americans distrust authority. Having grown up with a marginally rebellious attitude in my younger years, I am not completely unsympathetic to the mindset that authority should be questioned (particularly as my high school Principal, Mr. Sertell, was practically begging to have his judgement held up for scrutiny). But there's a difference between a healthy skepticism of official pronouncements (take the President's recent Afghanistan Surge speech as an example) and outright paranoia, and I have the sense that we've been increasingly shifting towards the latter perspective over the past decade.