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Cancer Haves And Have-Nots: Care And Treatment In 2 Different Worlds

By Michael J. Misialek, M.D.
Guest Contributor

Imagine feeling a lump on your body, visiting a doctor, and then waiting seven months (if you’re lucky) to find out whether it is cancer.

This has been the reality for the vast majority of patients in two of the world’s most impoverished nations, Rwanda and Haiti — both emerging from different but unthinkably grim histories of structural violence.

But since 2012, more patients are getting the care that everyone deserves, no matter what country they live in. A medical partnership between several Boston-based hospitals has radically reduced turnaround time for cancer diagnosis, and shrunk the number of people who fall through the cracks.

It is difficult to quantify the exact numbers here, since record keeping in the past has been poor. One data point: In Rwanda, where these interventions are in place, far fewer patients are lost to follow-up after they’ve been treated compared to patients in other poor countries, according to Dr. Larry Shulman, senior vice president for medical affairs at Dana-Farber Cancer Institute, and leader of the medical partnership.

As a pathologist at of one of these partner institutions — Newton-Wellesley Hospital — I can’t help but think about the patient behind the slides under the microscope. Here’s one: Tushime, an 11-year-old Rwandan girl, who had a large tumor protruding from her jaw.

The tissue sample from Tushime’s tumor arrived in Boston in a suitcase carried by an employee of Partners in Health, the global nonprofit. Like all other specimens, hers was processed into a slide by the pathology department of Brigham and Women’s Hospital and read by Harvard faculty.

Tushime’s tumor turned out to be a rhabdomyosarcoma, a common childhood sarcoma. After 48 weeks of chemotherapy and surgery in Rwanda, she is now healthy and free of disease. Doctors there used standard chemotherapy for a cost of about $300 (which was covered by Partners in Health, Dana Farber and the Rwandan government). They relied on age-old, tried and true chemotherapy drugs; in comparison, the newer chemotherapy agents in the U.S. often cost several thousands of dollars.

Even though access to care has improved dramatically in the developing world there is so much work to be done. There are patients who still present with tumors at an advanced stage, many being neglected for months or even years because of barriers to care. There’s often a lack of access to facilities for both diagnosis and treatment, and funding for cancer care is limited. As a result, ordinary diagnoses become extraordinary.

This is an image of a less aggressive (low grade) breast cancer, something that is fairly common among patients in the U.S. You can see the well formed tubules and glands of cancer, but fewer tumor cells growing in a more organized fashion -- only about 30 percent of the image is tumor. (Courtesy of Michael J. Misialek)

This is an image of a less aggressive (low grade) breast cancer, something that is fairly common among patients in the U.S. You can see the well formed tubules and glands of cancer, but fewer tumor cells growing in a more organized fashion — only about 30 percent of the image is tumor. (Courtesy of Michael J. Misialek)

This is an image of an aggressive (high grade) breast cancer not uncommonly diagnosed among patients in countries where access to medical care is limited, such as Haiti. You can see a solid mass of cancer -- the photo is 100 percent tumor. (Courtesy of Michael J. Misialek)

This is an image of an aggressive (high grade) breast cancer not uncommonly diagnosed among patients in countries where access to medical care is limited, such as Haiti. You can see a solid mass of cancer — the photo is 100 percent tumor. (Courtesy of Michael J. Misialek)

Under my microscope, I’ve seen some of the most aggressive appearing tumors from patients in these countries. What are typically rare cancers here in the U.S., such as sarcomas or unusual variants of breast cancers, are all too common in developing nations. Continue reading

New Spending Bill Adds Abortion Coverage For Peace Corps Rape Victims

File this under: “About #$@%&*! Time.

Tucked away in the recently passed $1.1 trillion federal spending bill is a provision that, according to women’s health and abortion rights advocates, is long overdue, ending a 35-year-old ban. The new measure offers abortion coverage to Peace Corps volunteers victimized by rape, incest or facing a life-threatening pregnancy; similar coverage is already provided to federal employees.

Bryan Dwyer, director of Peace Corps and Training in Kigali, Rwanda, and a Peace Corps volunteer in El Salvador from 2000-2002, expressed his strong approval for the new measure:

As both an RPCV [Returned Peace Corps Volunteer] and staff member, I am very pleased that PC [Peace Corps] Volunteers will now be afforded this protection, even as I earnestly hope that no one ever needs to avail herself of it.

Another former Peace Corps employee I talked to was a bit more blunt:

In a long overdue concession to reality, conservative members of Congress no longer forced their abusive “no choice no matter what” policy on women in the Peace Corps. For far too many years, they had prevailed in insisting that women who choose to serve our country who had been raped and impregnated should be repaid with no health care coverage to end those pregnancies. I am glad this truly appalling policy is finally at an end.

Edson Chilundo/flickr

Edson Chilundo/flickr

Here are more details and background in a Glamour magazine report:

Over the weekend, the Senate passed a $1.1 trillion spending bill that includes a provision to provide abortion coverage for Peace Corps volunteers in cases of rape, incest, or life endangerment.

It’s an important win for reproductive rights advocates in a year plagued by restrictions on abortion and other women’s health measures. President Obama is expected to sign the bill into law, granting Peace Corps volunteers and trainees the same type of abortion coverage offered to federal employees….

Currently, just over 60 percent of Peace Corps volunteers are female, and many of them work in areas with little to no access to safe, reliable health care. Continue reading

Really? SEAL Who Shot Bin Laden ‘Screwed’ Out Of Health Care?

(Esquire magazine)

(Esquire magazine)


Here’s a bit of a brouhaha that’s sure to fuel newsstand sales of Esquire magazine:

Under the irresistible headline “The Man Who Killed Osama Bin Laden…Is Screwed,” Esquire Magazine posts here its cover story for March. It begins:

For the first time, the Navy SEAL who killed Osama bin Laden tells his story — speaking not just about the raid and the three shots that changed history, but about the personal aftermath for himself and his family. And the startling failure of the United States government to help its most experienced and skilled warriors carry on with their lives.

But now confusion and controversy is swirling over whether, in fact, the man identified only as “the shooter” will in fact be quite so screwed. NPR’s ‘the two-way’ blog covers the back-and-forth here, including the latest at this writing:

Update at 8:12 p.m. ET. SEAL Is Eligible For Benefits
Stars and Stripes is reporting that all combat veterans of the wars in Iraq and Afghanistan are “automatically eligible for five years of free healthcare through the Department of Veterans Affairs.”
The newspaper also interviews Phil Bronstein, who wrote the Esquire piece. You can visit the Stars and Stripes website to see what he said.

Readers? Perhaps the point here is that we live in a country where it is even possible that a long-serving soldier could lack health care. Whatever your viewpoint, you may get a dark laugh out of this trenchant comment on NPR:

He can write “I killed Osama” on his resume. That is good for any mall cop position in America.

(Hat-tip to Ben Swasey)

Mystery Medicaid Shoppers Coming To Massachusetts?


Columbus Business First reports here:

It can be difficult to line up that first appointment with a new family doctor, but is it harder if you’re on Medicaid, or have a host of chronic ailments?

The federal government is planning a “mystery shopper” approach to find the pinch points in availability of primary care physicians, according to a Federal Register notice.

The Department of Health and Human Services is seeking approval for a study in which researchers will call more than 4,100 doctors’ offices in nine states and seek appointments posing as patients “with a range of medical needs.” Each office will get two calls, one from someone posing as a privately insured patient, and once from a simulated patient on Medicare or Medicaid.

The nine states are Florida, Hawaii, Massachusetts, Minnesota, New Mexico, North Carolina, Tennessee, Texas and West Virginia.

Anybody want to predict what the “mystery shopper” here in Massachusetts will encounter? I fear it won’t be pretty…

Here’s the Federal Register describing the plan and seeking comment. And here’s another report on the plan, followed by comments.
Hat-tip to my eternal hero, Herald grad Tom Mashberg, for amazing story-spotting.