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Yes, Medicare Will Cover Lung Cancer Scans For Longtime Smokers, But…

(Source: Wikimedia Commons)

(Source: Wikimedia Commons)

…to finish the sentence in the headline: But it was not the simple no-brainer that you might think.

Lung cancer is the biggest cancer killer of all, causing 160,000 American deaths a year. But should we use lung scans to screen longtime smokers en masse for it? That question has been vigorously debated of late in medical circles, as Medicare has weighed whether to pay for the scans.

This week, Medicare announced that it did indeed propose to cover annual low-dose CT scans for smokers and former smokers, ages 55 to 74, with a smoking history equivalent to a 30-year pack-a-day habit. (More details here.)

People say ‘You deserve this because you brought it on yourself, and thus, suffer the consequences.’
– Laurie Fenton Ambrose

The draft decision now gathers public comment for a month and will still need to be finalized, but cancer activists and some doctors are already hailing it as a victory. Laurie Fenton Ambrose, president of the Lung Cancer Alliance, which had helped lead the push for the coverage, predicted that the scans would save tens of thousands of lives.

So why has screening for lung cancer sparked such hot debate? Why did it even recently trigger a rare point-counterpoint duel in the pages of a major medical journal, JAMA Internal Medicine?

Well, first, the pendulum has been swinging lately towards greater skepticism about routine cancer screening, from mammograms to prostate tests.

(Source: FDA)

(Source: FDA)

At issue is the pivotal question of whether some forms of cancer screening do more harm than good, given that some of the tumors they pick up would never have caused any trouble. Routine blood tests for prostate cancer have fallen out of favor, for example, and the New England Journal of Medicine just published a cautionary tale from Korea about how mass ultrasound scans for thyroid cancer saved no lives.

So that’s the broader medical context. Then there’s the money. I recently heard a Medicare official say with pained realism at a public forum, “We can’t cover everything good.” Close to 5 million people on Medicare would be eligible for the screening, NPR reports, and the scans cost an estimated $241 each.

So at a time of greater emphasis on health costs and greater doubts about cancer screening, “We just found ourselves caught in that crossfire,” said Fenton Ambrose of the Lung Cancer Alliance.

With lung cancer, there’s also the question of special stigma. People say “You deserve this because you brought it on yourself, and thus, suffer the consequences,” Fenton Ambrose said. “It has always had that type of stigma, that even carried through in some of the public comments that came forth during the Medicare consideration.”

Dr. Chrisopher Lathan, a medical oncologist at the Dana-Farber Cancer Institute, similarly cited stigma as a source of “hesitation” on the coverage. “This is a cancer that’s heavily linked to a behavior,” he said. “The amount of data needed to convince everyone that this was a good screening tool — that hurdle was much higher. And also, we are in a more skeptical time, academically, when we look at screening. We know that screening is good, but it’s good in certain circumstances.”

Which circumstances, when it comes to lung scans? This is the moment for the Public Service Announcement that says, “Talk with your doctor.”

“At the end of the day, this is about the relationship between doctors and patients,” Fenton Ambrose said. And in particular, there are some gray areas that require discussion, she noted. What if, for example, you’re a bit younger, or smoked a bit less than the cut-off? Research is now under way on that “second tier” of potential scan subjects, she said. Continue reading

Boston Nurse Records 'Desperately Sad' Experiences Treating Ebola Patients In Liberia

Workers are next to the body of a woman suspected of dying from Ebola, before they offload her at a gravesite near the Bomi County Ebola clinic, on the outskirts of Monrovia, Liberia. (Abbas Dulleh/AP)

Workers are next to the body of a woman suspected of dying from Ebola, before they offload her at a gravesite near the Bomi County Ebola clinic, on the outskirts of Monrovia, Liberia. (Abbas Dulleh/AP)

A growing number of doctors, nurses and public health specialists across the U.S. are putting their lives on hold and heading to Ebola-ravaged regions of West Africa. Today, and in the months to come, we bring you the story of one man who is on the ground in Liberia.

John Welch, 33, is a nurse anesthetist at Boston Children’s Hospital, and works with Partners in Health (PIH) in Haiti. At least that was his life before he opened an email from the organization in late September. It was a call for volunteers and support as PIH moved into Liberia and Sierra Leone to try and stop Ebola’s spread. Welch told a supervisor he’d be happy to help if needed.

That decision, says Welch, “was about being on the right side of history. I think I would have trouble looking back, knowing that I had an opportunity, and had not stepped up.”

Welch meets sister Heidi Christman and niece Lydia in Columbus, Ohio, to explain why he's going to Liberia. (Courtesy of John Welch)

Welch meets sister Heidi Christman and niece Lydia in Columbus, Ohio, to explain why he’s going to Liberia. (Courtesy of John Welch)

Calming worried friends and family members was not so easy.

“How does your mother feel?” asks Lindsay Waller, an old friend and fellow anesthetist, who helps Welch prepare to discuss the decision with his family.

She’s upset and worried, Welch says, but “I am who I am because she’s my mother. [My parents] taught me these feelings of altruism and taking care of the people around you and helping out.”

The next day, on a quick trip from Boston to Columbus, Ohio, Welch makes a pitch he knows will resonate with his mother, aunt and sister: 70 percent of deaths from Ebola are women, the caregivers.

He asks his family to sit with him and watch a “Frontline” episode on Ebola. Fear and pain in the faces of patients with Ebola made the point for Welch.

“At first, I wanted to just say, ‘No, don’t go, it’s too dangerous,’ ” says Heidi Christman, Welch’s sister. But then, in the video, Christman says she saw “the brothers and sisters, friends and family that have been lost because of Ebola. And it made me realize that it’s not about me or my fears. It’s about helping these people. They deserve people like my brother.”

Her brother flew to Alabama for a CDC Ebola treatment training and in mid-October, three weeks after Welch said, “I’m in,” he was on his way to Liberia.

It wasn’t an easy journey. There are very few flights in and out of Liberia these days. Welch had several cancellations, spent an extra day in Casablanca, and his luggage was lost in transit.

When he finally lands in Liberia, Welch must take his temperature and wash his hands in chlorine, something he’ll get used to doing at least a dozen times a day. On the drive into Monrovia, a building, all lit up, stands out from a distance. Welch realizes it’s the large Doctors Without Borders Ebola Treatment Unit that he’s read about and seen in pictures. Suddenly, his assignments feels real.

After a few hours sleep, Welch leaves Monrovia and heads inland to a clinic in rural Bong County run by the International Medical Core. Welch is here to learn what it will take for PIH to set up a similar Ebola Treatment Unit in another rural county with few roads, power lines and little running water.

Continue reading

The Bionic Mind: Building Brain Implants To Fight Depression, PTSD

Liss Murphy this summer, with husband Brian, son Owen and sheepdog Ned. (Courtesy)

Liss Murphy, who had surgery to implant Deep Brain Stimulation for depression in 2006 and got much better, on Cape Cod in summer, 2014, with husband Scott, son Owen and sheepdog Ned. (Courtesy)

Ten years ago, with little warning, Liss Murphy fell victim to paralyzing depression, a “complete shutdown.”

She was 31, living in Chicago and working in public relations. The morning of Aug. 13, 2004, she had gone in to the office as usual. “It was Tuesday, and I remember the day so clearly,” she says. “The sun — everything — and I walked out — it was about 11 o’clock — and I never went back. The only time I left the house was to see my psychiatrist, who I saw three times a week.

“I have a hard time believing it was depression, in a way, because it was so pervasive and powerful,” she says. “It invaded every aspect of my life. It took so much away from me. And it happened so fast, and it was so degrading — it took everything from me.”

Murphy came home to Boston, and she tried everything — medications, talk therapy, even repeated rounds of electroshock. But she was barely able to get out of bed for months — then years. Her husband and family and top-flight doctors cared for her, but she sank so low she tried twice to commit suicide.

Finally, a psychiatrist told her about a cutting-edge trial to implant stimulation devices deep in the brains of patients with severe depression. She signed up. In June of 2006, she had the operation.

“My greatest hope that day was to have something go horribly wrong and die on the table,” she says. “I didn’t care.”

She didn’t die. Over the next few months, she got better. These days, eight years after the surgery, if you saw Liss Murphy walking her Old English Sheepdog, Ned, or playing with her 3-year-old son, Owen, only the faint silver scars on her clavicles would hint at anything unusual: That’s where the batteries that power her brain stimulator are implanted.

“We’re taking a wall of computers, basically, and putting it into something that would easily fit inside a box of Tic-Tacs.”
– Jim Moran, Draper Laboratory

But though the surgery changed Murphy’s life, “the trial, on average, didn’t work,” says Dr. Emad Eskandar, the Massachusetts General Hospital neurosurgeon who operated on her. “When you pooled everyone together it didn’t work. But there were like five people out of the 10 we did that had remarkable benefits and went into complete remission. We couldn’t continue with the study because on the average it failed, but for those people in whom it worked, boy did it work.”

Now, as part of a $70-million project funded by the military, researchers are aiming to take brain implants for psychiatric disorders to the next level.

Over the next five years, they aim to build a device that can sit inside a patient’s head, pick up the onset of depression or post-traumatic stress disorder, and head it off before it hits. One implant researcher calls it “a moonshot for the mind.” Continue reading

Where Baker, Coakley Stand On Health Care

Democrat Martha Coakley and Republican Charlie Baker, before a televised debate Tuesday in Boston (Barry Chin/Boston Globe/Pool/AP)

Democrat Martha Coakley and Republican Charlie Baker, before a televised debate Tuesday in Boston (Barry Chin/Boston Globe/Pool/AP)

It’s nearly half the state budget, almost 20 percent of the state’s economy and a perennial top concern for voters. The issue is health care, and so far, neither Democrat Martha Coakley nor Republican Charlie Baker has taken the lead on this topic with voters in the gubernatorial race.

“Coakley has perhaps a slight edge on the general health care issue, as well as the affordability issue, but neither campaign has really broken away” on health care, said Steve Koczela, president of the MassINC Polling Group. “It’s not like taxes, which go big for Baker. It’s not like education, which tends to go a bit bigger Coakley. It’s an issue that is still very closely fought.”

So where do the gubernatorial candidates stand on some of the key concerns in health care? Below is a summary of the candidates’ proposals for how to treat the health of the state.

On Making Health Care More Affordable:

BAKER: He argues that giving patients information about how much tests and procedures cost, in advance, will help us become informed consumers of care. We’ll spend less money, because we’ll choose to have a baby, for example, at the hospital with the lowest cost and best quality scores. As of Oct. 1, health plans in Massachusetts are required to post what they pay each hospital and doctor.

Baker would take a next step. “I’d like to get to the point where hospitals just post prices and people can see them plain as day,” Baker said. “As governor, I’m going to lean really hard on this.”

Some health care analysts say Baker’s strategy for reducing health care costs could backfire. Patients may assume that the most expensive hospital is the best even though that’s generally not true. And letting Brockton Hospital, for example, know that it is paid about half of what Massachusetts General Hospital receives for a C-section may mean Brockton Hospital demands more money, instead of MGH saying, “OK, I’m going to lower my prices to compete.” In addition, some of the expensive hospitals say their higher prices subsidize teaching and research.

COAKLEY: She argues she is uniquely positioned to tackle health care spending. She created a health care division in the attorney general’s office, issued the first detailed reports on health care costs and used her leverage to negotiate a deal that would limit the price increases Partners HealthCare could demand in the near future.

“The agreement that we have reached, to be approved by the court, caps costs and lowers costs as opposed to maintaining the status quo, which we all agree is too expensive,” Coakley said during a campaign debate on WBZ-TV. Continue reading

Opinion: Why America’s Ebola Fears Are Dangerously Misplaced

Cpl. Zachary Wicker demonstrated the use of a germ-protective gear in Fort Bliss, Texas on Tuesday. (Juan Carlos Llorca/AP)

Cpl. Zachary Wicker demonstrated the use of a germ-protective gear in Fort Bliss, Texas on Tuesday. (Juan Carlos Llorca/AP)

By Richard Knox

At the memorial service last weekend for the only person to have died of Ebola on American soil, the Liberian clergyman who eulogized his countryman Thomas Eric Duncan posed a question we all should be thinking hard about right now.

“Where did Ebola come from to destroy people — to set behind people who were already behind?” Methodist Bishop Arthur F. Kulah wondered.

Here’s the reality: Until the world (and especially the United States of America) refocus on the “people who were already behind” in this battle of virus-versus-humanity, no one can rest easy.

Ebola is an animal virus that has sporadically caused local human outbreaks in Africa for at least 38 years. But now it has crossed into people who live in densely populated African nations with barely functioning health systems and daily jet connections to the rest of the planet.

“It’s like you’re in your room and the house is on fire, and your approach is to put wet towels under the door.”
– World Bank chief Jim Yong Kim

This is entirely predictable, as scientists who watch emerging diseases have long known. They just didn’t know which virus would be the next to terrorize the world. (SARS and HIV showed how it can happen, remember?)

Those of us who, like me, report on global public health have a sense of inevitability as we watch the Ebola crisis unfold. We always knew it would mostly affect, as Bishop Kulah so aptly puts it, “people who were already behind.”

And we knew the people least affected by this scourge — privileged denizens of wealthier countries — would overreact out of misplaced fear for themselves, rather than a reasoned and compassionate understanding about what needs to be done.

So we see the freaked-out, wall-to-wall, feedback-loop media coverage we’re experiencing now. Schools closing down in Ohio for completely unnecessary disinfection. Recriminations against hapless health workers who suddenly find themselves dealing with an exotic new threat. Continue reading

Outbreak On Trial: Who’s To Blame For Bringing Disease Into A Country?

Francina Devariste, 3 years old, is one victim of an ongoing cholera outbreak in Haiti that has killed 8,000 people and sickened over 700,000. (2010 photo courtesy of the United Nations)

Francina Devariste, 3 years old, is one victim of an ongoing cholera outbreak in Haiti that has killed 8,000 people and sickened over 700,000. (2010 photo courtesy of the United Nations)

By Richard Knox

If an international agency introduces a devastating disease to a country, should it be held accountable?

That’s the big question at the heart of a court proceeding that gets underway next Thursday. The international agency is the United Nations. The disease is cholera. And the nation is Haiti.

Four years ago this month, thousands of Haitians downstream from a U.N. peacekeeping encampment began falling ill and dying from cholera, a disease not previously seen in Haiti for at least a century.

Since then cholera has sickened one in every 14 Haitians — more than 700,000 people; and over 8,000 have died. That’s nearly twice the official death count from Ebola in West Africa thus far.

A year ago, a Boston-based human rights group sued the U.N. for bringing cholera to Haiti through infected peacekeeping troops from Nepal, where the disease was circulating at the time. The U.N. camp spilled its sewage directly into a tributary of Haiti’s largest river.

There’s little doubt that the U.N. peacekeepers brought the cholera germ to Haiti. Nor is there argument over the poor sanitary conditions at the U.N. camp.

When I visited the scene in 2012, it was plain how untreated sewage from the camp could easily contaminate the Meille River that runs alongside before it spills into the Artibonite — Haiti’s Mississippi — which provides water for drinking, washing and irrigation for a substantial fraction of the country’s population.

The smoking gun, scientifically, is a molecular analysis of the Haitian cholera bug compared to the Nepalese strain from the same time period. It showed the two differ in only one out of 4 million genetic elements.

“That’s considered an exact match, that they’re the same strain of cholera,” Tufts University environmental engineer Daniele Lantagne told me last year. Continue reading

Mass. Becomes First State To Require Price Tags For Health Care

CLICK TO ENLARGE: Massachusetts residents can now shop for their health care online, seeing prices for procedures and visits. (screenshot)

CLICK TO ENLARGE: Massachusetts residents can now shop for their health care online, seeing prices for procedures and visits. (screenshot)

Massachusetts has launched a new era of shopping. It began last week. Did you notice?

Right this minute, if you have private health insurance, you can go to your health insurer’s website and find the price of everything from an office visit to an MRI to a Cesarean section. For the first time, health care prices are public.

It’s a seismic event. Ten years ago, I filed Freedom of Information Act requests to get cost information — nothing. Occasionally over the years, I’d receive manila envelopes with no return address, or secure .zip files with pricing spreadsheets from one hospital or another.

Then two years ago Massachusetts passed a law that pushed health insurers and hospitals to start making this once-vigorously guarded information more public. Now as of Oct. 1, Massachusetts is the first state to require that insurers offer real-time prices.

“This is a very big deal,” said Undersecretary for Consumer Affairs and Business Regulation Barbara Anthony. “Let the light shine in on health care prices.”

There are caveats.
Continue reading

If You Build A Crew Program For Overweight Kids, They Will Row — And Get Fitter

There was no comfortable place for 17-year-old Alexus Burkett in her school’s typical sports program of soccer and lacrosse and basketball.

“They don’t let heavyset girls in,” she says.

Alexus was “bullied so bad about her weight,” says her mother, Angelica Dyer, “and there was no gym that would take her when she was 14, 15 years old. There was no outlet.”

But Alexus has found a sports home that is helping her bloom as an athlete: an innovative program called “OWL On The Water” that offers rowing on the Charles River specifically for kids with weight issues.

She has lost more than 50 pounds over half a year, but more importantly, says her mother, “They’ve given me my daughter’s smile back.”

Alexus Dwyer during warm-ups before instruction time. (Jesse Costa/WBUR)

Alexus Burkett stretches during warm-ups before “OWL On The Water” instruction time. (Jesse Costa/WBUR)

“It’s given me a lot of good strength and it’s making me more outgoing,” Alexus says. “We’re all best friends and we’re all suffering with the same problem — weight loss — so we’re more inspiring each other than we are competing against each other.”

OWL On The Water offers a small solution to a major national problem: According to the latest numbers, 23 million American kids are overweight or obese, and only about one quarter of 12-to-15-year-olds get the recommended one hour a day of moderate to vigorous physical activity. Heavier kids are even less likely to be active, and only about one-fifth of obese teens get the exercise they need, the CDC finds.

“I know I need to be active, but please don’t make me play school sports!” That’s what exercise physiologist Sarah Picard often hears from her young clients at the OWL — Optimal Weight for Life — program at Boston Children’s Hospital that sponsors OWL On The Water.

Many gym classes still involve picking teams, “and my patients are the ones that are always picked last,” she says. “You’re the biggest one, you’re the last one, you’re picked last, and you’re uncomfortable.”

They are strong, powerful people.
– Sarah Picard

School fitness testing is important, Picard says, but it, too, can be an ordeal: “I have kids who sit in my office and tell me that they didn’t go to school for a week because they wanted to miss the fitness testing,” she says.

While many a coach might see bigger bodies as poorly suited to typical team sports, Picard sees them as having different strengths. Particularly muscular strength.

“What I’ve observed is that these kids are much better at strength and power-based activities,” she says. And rowing is particularly good for them, she says, because though it is strenuous, it is not weight-bearing, and thus more comfortable for heavier bodies — yet a heavier, strong body can pull an oar much harder than a smaller person’s body. The program begins by building on that muscular strength, she says, and then works on aerobic fitness. Continue reading

Boston-Based Partners In Health Leaps Into Ebola Crisis

Members of Partners in Health work with representatives from Liberia and Sierra Leone via conference call to help combat the Ebola outbreak. (Jesse Costa/WBUR)

Members of Partners in Health work with representatives from Liberia and Sierra Leone via conference call to help combat the Ebola outbreak. (Jesse Costa/WBUR)

An advance team from Boston-based Partners In Health heads for Ebola-stricken Liberia Monday. Four doctors, including co-founder Paul Farmer, and two operations staff will lay the groundwork for an ambitious two- to three-year project that will require well over 100 volunteer doctors, nurses, lab techs and public health workers. The budget for just the first year is $35 million.

“We are at a dangerous moment with Ebola,” said Farmer as he prepared for the trip. “Even though this is a huge jump for PIH, I am confident we will succeed.”

PIH will work with two established groups, Last Mile Health in Liberia and Wellbody Alliance in Sierra Leone, to strengthen existing public health clinics and train several hundred new community health workers. In addition, PIH will open two 50-bed Ebola treatment centers in rural areas of each country.

The plan began to take shape last week, as the World Health Organization reported a near doubling of Ebola cases in Liberia and an estimate from Columbia University projects 30,000 cases by mid-October if conditions in the country deteriorate.

“There’s more doctors on a single floor of the Brigham than in the entire country of Liberia.”
– PIH's Paul Farmer

In the colorful offices of PIH, decorated with art from countries where the group works, some staffers are flashing back to 2010 and the weeks following Haiti’s earthquake. Ebola is creating another humanitarian crisis, one that is unfolding right before their eyes.

The call for volunteers went up on PIH’s website five days ago. More than 100 people responded within 24 hours, but it will take some time to determine if the skills of applicants fit the needs of these rural Ebola treatment and isolation units. PIH is trying to screen potential recruits quickly. It plans to send a first round to a training run by the Centers for Disease Control next week and open the centers by mid-October or early November.

“To do this right, we will depend on people who are willing to fight against this terrible crisis,” said Joia Mukherjee, chief medical officer at PIH. “The reason we will need a lot of non-Liberians, non-Sierra Leoneans — these countries simply do not have enough doctors and nurses.”

“There’s more doctors on a single floor of the Brigham than in the entire country of Liberia,” added Farmer, who is also chief of the Division of Global Health Equity at Brigham and Women’s Hospital.

He hopes to tap the medical wealth of Boston for the Ebola project, but the PIH board has demanded that a plan to treat and evacuate sick volunteers is in place before the operation begins. Farmer and Mukherjee are talking to the U.S. Department of Defense and other possible partners about transportation and care options.

A fourth doctor in Sierra Leone died Saturday, bringing the total number of health care worker deaths in Liberia, Sierra Leone and Guinea from Ebola to 150. Continue reading

From Pimples To Desire, What Might Happen When You Ditch The Pill

(Becca Schmidt/Flickr via Compfight)

(Becca Schmidt/Flickr via Compfight)

By Veronica Thomas
Guest Contributor

So you’re thinking about going off the pill. Maybe you’ve been feeling depressed, getting headaches, or keep forgetting to pop the tiny tablet. Perhaps you’ve been experiencing some really strange stuff that didn’t happen before you started the pill—like inflamed, bleeding gums or cringing at another person’s touch.

Both personal anecdotes and research studies have linked these and other side effects, such as breast tenderness and nausea, to the pill. (One study suggested it might even make you pick the “wrong” partner by altering your chemical attraction to a man’s scent.)

Most randomized control trials haven’t actually found any real difference in the frequency of side effects among women taking the pill versus those taking a placebo.

“It’s an interesting phenomenon,” says Dr. Alisa Goldberg, director of clinical research and training at the Planned Parenthood League of Massachusetts. “Clearly some women are sensitive to the pill and experience these things, but when you try to study it scientifically on a population basis, there’s really no difference.”

Still, while four out of five American women have used the pill at some point, 30 percent have discontinued its use due to dissatisfaction—most commonly because of its side effects. The latest federal statistics on contraception use are due this fall, and experts expect trends from recent years to continue: IUD use will continue to rise, while pill use seems to have plateaued.

I tried five different formulations of the pill, but never managed to escape all the annoying symptoms.

The issues a woman experiences—or whether she has any at all—vary greatly based on the specific dosage of hormones and the unique individual swallowing them every day. Personally, along with bloating and mood swings, I got migraines with an aura, or what felt like a laser light show in my left eyeball. Twice I had to retreat to my office’s “Pump and Pray Room”—reserved for new mothers and religious employees—to lie down and recover. (What I did not know at the time was that, because of this symptom, I should not have been on an estrogen-containing pill in the first place. Women with aura migraines, along with other conditions that put them at risk for strokes, blood clots, heart disease or some cancers, should not take combination pills.)

Finally, I gave up on the pill—only to be blindsided by a whole new challenge: the unexpected side effects of going off the pill. To help others avoid similar unpleasant surprises, I spoke with three experts about what to expect when you ditch the pill for another birth control method.

Of course, just as each woman has a unique reaction to the pill, she’ll also have a unique reaction to going off. According to the feminist women’s health organization Our Bodies, Ourselves, there is “enormous variability in any individual’s response to her own hormones or any synthetic hormones she takes.” One woman’s skin may break out in pimples, while another’s clears up completely.

With this disclaimer in mind, here are eight possibly unexpected changes you might experience when you cancel your monthly refill of that crinkly foil packet:

1. Most of the side effects should disappear in a few days.

First off, while many women decide to have their period before pitching the pack, it’s safe to stop taking the pill at any point. However, you should stop immediately if experiencing any serious side effects, like headaches or high blood pressure, says Dr. Jennifer Moore Kickham, the medical director of a Massachusetts General Hospital outpatient gynecology clinic. Continue reading