May yield substantial benefits: The fifth birthday of the Massachusetts universal health insurance law

In 1993, John Ayanian and a team of researchers studied the detection and treatment of breast cancer among women in New Jersey with and without health insurance. In their widely cited article in the New England Journal of Medicine about the harm to women's health of the lack of insurance, they concluded, "Comprehensive programs to improve access to early detection and optimal treatment may yield substantial benefits." Little did they know.

Fast forward to 2011, and the recent fifth birthday of the passage in Massachusetts of a state law requiring near-universal health insurance, Chapter 58 of the Acts of 2006. By my calculations, the new coverage for many thousands of women has likely led to the earlier detection and treatment of breast cancer, saving the lives of dozens of women each year, and more than 200 since the law went into effect. It would be interesting to see more precise calculations. Perhaps this could be an exercise for public health students.

Happy Birthday, and many more!

Read about the first birthday of the Massachusetts health reform law.

Ultimately Congress will decide: Inappropriate mammograms in young women

Ultimately Congress will decide: Inappropriate mammograms in young women

Earlier, I wrote about an inspiring legislator and cancer survivor about U.S. Rep. Debbie Wasserman Schultz. She has now filed legislation, with 350 Congressional co-sponsors, promoting the early detection of breast cancer in young women. Ultimately, she says, Congress will decide.

I admire her determination and passion, and I still consider her a patient advocate heroine.

Yet her efforts are likely to create more suffering than healing. The breast tissue of young women is usually too dense for routine mammograms to be effective. The radiation exposure of mammograms can itself be problematic. Young women rarely get breast cancer. The false positive readings from their mammograms are likely to find too many medically insignificant nodules that would lead doctors to perform unnecessary biopsies, in which tissue is removed for testing. Scarring from the biopsies could make breast cancer harder to detect when the women are older and have a much higher risk of breast cancer. False alarms can lead women to distrust their doctors and skip mammograms later in life when the tests have been shown to reduce the death toll, according to Dr. Otis Brawley, the chief medical officer of the American Cancer Society. Similarly, breast self-exams can lead young women to detect small irregularities of no medical significance. While breast self-exams and mammograms of women in their 40s and older do indeed save lives, self-exams and mammograms of women in their 20s and 30s have not proven to result their death toll, according to Dr. Susan Love, a prominent breast cancer surgeon.

Perhaps in the future, mammography will improve to more accurately detect cancers in young women’s dense breast tissue. Until then, advocates have to look hard at the facts, and have to think carefully about what advice will truly minimize the suffering of young women.


Advice to mothers of young women: Read the excellent New York Times article by Natasha Singer on July 17 about public health experts' criticism of early mammograms, before advising your daughters.

Read a story about anxiety from false positive mammograms.

The highlight of my 28-year career: Early detection of oral cancer

Nancy is a registered dental hygienist. Here’s her story:
This 70-year-old woman has been a patient of mine for many years. Because of her periodontal disease history she comes in every 3 months for cleanings. She has been a smoker since she was 14 years old. She has smoking-related health problems - emphysema and pulmonary fibrosis. Her smoking has also taken a real toll on her oral health. Moderate bone loss, loss of teeth and a failed implant bridge.

During one of her cleanings I noticed a small red area on the floor of her mouth. Just an irritation? Maybe. But I couldn't ignore it. We sent her to the oral surgeon. The phone call was shocking! It was a squamous cell carcinoma. We caught it at a very early stage and they were able to remove it. No other treatment was needed. The oral surgeon's final words: "Congratulations, you saved her life." WOW! That for sure was the highlight of my 28 year career.

Cancer exams save lives! and PLEASE QUIT SMOKING!!!!!!! A final note: After 50 years of smoking this patient kicked the habit! Way to go!

Advice to people who haven't seen a dentist lately: It's uncomfortable but rarely painful. Call around first to see what they do to make it more comfortable for patients; then go.

Read another story on how timely dental care could have saved a life. Thanks to Dr. William L. Eickhoff of North Palm Beach, Florida for the post on his blog on July 9.

When she had a second check: Kylie Minogue's breast cancer misdiagnosis

The Australian pop star Kylie Minogue appeared as a guest a few months ago on comedienne Ellen DeGeneres' TV talk show. She had just heard Ellen and her earlier guest, Senator Hillary Clinton, discuss the importance of the early detection of breast cancer. Ellen asked Kylie about her bout with breast cancer two years before.

"Listen, this is an opportunity for me to say something that I have not said before," Kylie said.
"I was misdiagnosed initially. So my message to all of you and everyone at home is, because someone is in a white coat and using big medical instruments doesn't necessarily mean they are right."

The misdiagnosis had happened before she embarked on her Showgirl concert tour. Later, when she had a second check, it was discovered she had breast cancer. She is now in remission.
Ellen DeGeneres also told the audience she had a mammogram and was given the all clear, but then "a couple of weeks later" she found a lump in her breast and had it removed.

Kylie Minogue's advice to women tested for breast cancer: "If you have any doubt, go back again."

Read a story of delayed detection of breast cancer.

The source article appeared in the Sydney Morning Herald of April 8, 2008.

I am incredibly and eternally grateful: Early detection of cancer through digital mammography

As a woman whose first digital mammogram revealed a potential abnormality, I was calm for the repeat imaging, expecting it to be normal on the second look.

My anxiety increased, however, during the next few months as I progressed to a series of more elaborate, more invasive tests and biopsies, and a diagnosis of a small, in situ cancer, now successfully treated.

Despite the extremely harrowing, sleepless and depressing few months (mostly spent waiting for the next procedure), I am incredibly and eternally grateful for digital mammography and for its medical practitioners who made my very early diagnosis possible.

Sally Chrisman's Advice: Don’t delay your mammograms, even if you are anxious about a possible call back. Early detection definitely saves lives.

Read another mammogram story.

Thanks to Sally Chrisman for writing to the editor of the NY Times, published in today's issue.

My annual physical was a lifesaver

David Evett's letter to the editor:

Stephen Smith's article: "The annual physical gets a checkup" (Health/Science, Oct. 22) questions the value of the yearly visit to the doctor. I am an active, energetic 71-year-old. Between Christmas and New Year’s 2005-2006, I had a mild case of pneumonia, which yielded promptly to antibiotics. When I went in for my annual checkup the following April, I seemed to be in excellent general health. My conscientious doctor, however, ordered a chest X-ray to see whether the pulmonary infection had done any permanent damage. This was not an official follow-up: had I not come in for the exam, he would not have ordered the X-ray. It revealed no ill effects from the pneumonia. The alert radiologist, however, noticed a suspicious shadow in the other lung. It was cancer. Early detection meant early surgery and the strong likelihood that it would not recur. I need hardly say that I am glad – as are my family, friends, and professional associates – that I schedule that exam every spring.

Advice to elderly pneumonia survivors: Pneumonia can be dangerous for older people, so make sure the doctor follows up to ensure the infection has completely cleared up.

Read another prevention story.

Something women themselves can do: Avoiding ovarian cancer misdiagnosis

The mother of a friend died years ago from ovarian cancer, so the good news to be formally announced on June 25 about its early detection hits close to home.

Dr. Barbara Goff and her colleagues found that one-third of women with ovarian cancer had initially received a misdiagnosis, e.g., of depression, menopause, irritable bowel syndrome, or "growing old." She said, "12% were told there was nothing wrong with them, and it was all in their heads."

“There are so many horror stories of doctors who have told women to ignore these symptoms or have even belittled them on top of that,” said a co-author, Dr. Debbie Saslow.

Ovarian cancer can grow and spread quickly, so even a few months’ head start in getting the diagnosis can be vital.

"This is something that women themselves can do," said Dr. Carol Brown of Memorial Sloan Kettering Cancer Center, "and we can familiarize clinicians with, to help make the diagnosis earlier."

Advice to women: If over the last 2 - 3 weeks you have experienced near-daily bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly and feeling a frequent or urgent need to urinate, see a gynecologist, especially if this is new and different from your normal state of health.

Please help us spread the upcoming announcement by the Gynecological Cancer Foundation, the Society of Gynecologic Oncologists, and the American Cancer Society, by forwarding this to your friends.

Read another of our delayed diagnosis stories, or read Denise Grady’s source story in today’s New York Times.