Tuesday, December 06, 2011

E! talk show host Giuliana Rancic chooses double mastectomy for breast cancer treatment. Why this is the right choice

E! talk show host Giuliana Rancic, recently diagnosed with breast cancer (and having failed an attempt to remove the cancer with a lumpectomy) has decided to proceed with bilateral mastectomies and reconstruction for her treatment. Her decision is similar to those made by actress Christina Applegate and comedian Wanda Sykes in recent years. This choice is likely the right one for a number of reasons IMO.
  • at 37 years old and without children (she was actually undergoing fertility treatments when diagnosed with cancer), she possesses two significant independent risk factors for future breast cancer 1) personal history of cancer and 2) delay or absence of childbirth.
  • She has had prior attempt at lumpectomy, which almost guarantees significant cavitary breast deformity, particularly on a thinner woman such as Mrs. Rancic with additional attempts
  • She (being an American adult female in good health) has an estimated life expectancy of almost 95 years, and 6+ decades of future surveillance on a high risk individual treated with breast conservation strategies has not been studied. Mastectomy does seem to have an advantage of lower recurrence rates verus lumpectomy with radiation, particularly as you get decades out from the initial treatment.
  • A breast treated with lumpectomy and radiation will progressively look worse and worse over time as it relates to bot appearance and asymmetry with the other breast.
Selecting or suggesting a treatment for a younger patient like Mrs. Rancic becomes as much a question of psychology as it is about treatment of the cancer. While it's likely that a more aggressive surgical treatment of localized cancer will pay dividends as you get farther out from the mastectomy, many women will never be comfortable with the breast cancer surveillance requirements going forward and select a mastectomy to simplify their care. It's telling that when women plastic surgeons have been surveyed on whether they'd undergo mastectomy or breast conservation with radiation, that almost all of them would choose mastectomy (and prophylactic mastectomy of the other breast).


Monday, December 05, 2011

NJOM shows sick patients cost more to treat...... Who knew?

In the least surprising conclusion of recent articles in the New England Journal of Medicine (N. Engl. J. Med. 2011;365:1704-12,) it was proven that older, sicker patients cost more money to take care of!

from the summary in Internal Medicine News, 
"Eight commercial disease-management companies using nurse-based telephone care programs failed to improve quality of care, reduce hospital admissions, decrease emergency department visits, or cut health care costs in a pilot project of fee-for-service Medicare patients.

 Companies were required to meet preset targets for clinical quality and patient satisfaction, and to hold health care costs under a preset limit. An independent group, RTI International, won a competitive bid to evaluate the programs.

However, before the evaluation could be completed, five of the eight companies incurred such "substantial financial liability" that they terminated their programs, according to Nancy McCall, Sc.D., and Jerry Cromwell, Ph.D., of RTI International in Washington.
These findings show "it is unlikely that simply managing the care of elderly patients through telephone contact or an occasional visit will achieve the level of savings Congress had hoped for when it mandated the Medicare Health Support Pilot Program," Dr. McCall and Dr. Cromwell said."
So a majority of participating companies with extremely sophisticated resources to manage these patients could not make the numbers work, and Medicare is trying to capitate costs and financial risk of these patients onto providers in the future via "Accountable care Organizations" (ACO)?

This is the same thinking that led the geniuses who run Wall Street to put together a bunch of high risk,crappy mortgages together into a new vehicle, the synthetic  Collateralized Debt Obligation (CDO), and expect it to perform better then the underlying parts.  These products later nuked our economy by hyper accelerating speculative housing market bets.

Just as it took a physician running a hedge fund, Dr. Michael Burry (hero of the excellent book by Michael Lewis "The Big Short"), to point out that the emperor had no clothes in the housing bubble, major medical centers like the Mayo Clinic and Cleavland Clinic  have already told the government "no thanks!" on assuming open-ended risk on capitated care contracts for medicare patients.