Thursday, December 22, 2011

Opting to track, not treat, early prostate cancer | Lubbock Avalanche-Journal

WASHINGTON — John Shoemaker visited six doctors in his quest to find the best treatment for his early stage prostate cancer — and only the last one offered what made the most sense to the California man: Keep a close watch on the tumor and treat only if it starts to grow.
Very few men choose this active surveillance option. Yet Shoemaker is one of more than 100,000 men a year deemed candidates for it by a government panel. That's because their prostate cancer carries such a low risk of morphing into the kind that could kill.
The risk for them is so low, in fact, that specialists convened recently by the National Institutes of Health say it's time to strip the name "cancer" off these small, lazy tumors.
In the meantime, the panel wants more of those men offered the option of delaying treatment until regular check-ups show it's really needed. That endorsement promises to fuel efforts by the Prostate Cancer Foundation and a few other groups to spread the word to the newly diagnosed.
Shoemaker's journey shows how difficult that may be, from doctors who don't even bring it up to the fear factor.
"With prostate cancer, you hear the "C'' word, so to speak, and people freak out," says Shoemaker, 69, a businessman from Los Altos, Calif., who was intent on examining all his options.
Five years after his diagnosis — and five biopsies plus numerous blood tests and ultrasound scans later — Shoemaker's happy he found a surgeon who argued against immediate treatment. He's confident his prostate tumor hasn't grown, and avoided the pain and side effects of surgery or radiation.
Some 240,000 men a year in the U.S. are diagnosed with prostate cancer.
Earlier this month, the NIH-appointed panel found that most have the low-risk kind, a legacy of using problematic PSA blood tests to screen healthy men for possible signs of this slow-growing cancer that will affect most men's prostates if they live long enough.
Yet 90 percent of such men choose immediate treatment such as surgery or radiation, risking serious and long-lasting side effects, such as impotence or incontinence, without good evidence about who will live longer as a result. One recent study tracked 731 men diagnosed with early stage prostate cancer for 10 years and found no difference in survival between those who had surgery and those who weren't treated unless they went on to develop cancer symptoms, an older option known as watchful waiting.
Active surveillance is much more aggressive than watchful waiting — men get regular scans, blood tests and biopsies to check the tumor, although the NIH panel found the degree of monitoring can vary by medical center. Active surveillance is designed to monitor men closely enough that they can get curative treatment quickly if it looks like they'll need it, well before any symptoms would begin.
"It's not treatment versus no treatment; it's about timing of treatment," Shoemaker's physician, Dr. Peter Carroll of the University of California, San Francisco, told the NIH. He's a well-known prostate cancer surgeon who also leads one of the country's few large active-surveillance programs, tracking more than 900 men for over five years. Most are treatment-free so far, and none has gone on to die of prostate cancer.
What's the advice for men? The NIH panel said men with a PSA level less than 10 and a Gleason score that's 6 or less are candidates for this type of active surveillance. The Gleason score measures how aggressive prostate cancer cells look under the microscope. Urologists can provide those numbers.
Then what? Today, what men decide to do next largely depends on the advice of the specialist they wind up seeing, and many either don't offer active surveillance or present it in a negative way, as doing nothing, the NIH panel learned. There's also the patient's instinctive "get it out" reaction.
Enter the National Proactive Surveillance Network — at — a collaboration of two large active-surveillance programs, at Johns Hopkins University and Cedars-Sinai Medical Center, with the Prostate Cancer Foundation. First, it aims to educate men about active surveillance.
Within a few months, an interactive section of the site will be added to link men with doctors who offer active surveillance and track how they fare with input straight from the patients themselves, said Hopkins' Dr. H. Ballentine Carter.
"To me, it's an individualized approach rather than the one-size-fits-all approach of treating everyone," Carter says.
Beyond whether and how men choose surveillance, behavioral scientist Kathryn Taylor of Georgetown University wants to know how they decide to stick with it. About a quarter of men abandon the observation approach within two or three years, and as many as half by five years, the NIH panel learned. It's not clear how much of that was because they needed treatment, and how much was just the anxiety or getting tired of repeat biopsies.
Taylor is beginning a study of 1,500 newly diagnosed, low-risk prostate cancer patients at Kaiser Permanente in Northern California to see how many are told about active surveillance and what helped or hindered their decision.
"Living with untreated cancer is very difficult," she says, "and not everybody can do it, not surprisingly."

Doctor and Patient: A Medical School More Like Hogwarts -

It's been clear for several years now that while aspiring doctors may start medical school as happy and as healthy as their non-doctoring peers, four years later they aren't.

More than 20 percent end up with depression, more than half suffer from burnout, and in any given year, as many as 11 percent contemplate suicide. All of these statistics, of course, bode poorly for patients. Doctors who are burned out are more likely to make errors and to lose sight of the altruism that led them to go into medicine in the first place.

Fortunately, the subtext of this growing body of data — that there is something toxic about the medical education process — has not been lost on the educators who run this country's medical schools. Some have hired mental health experts for their institutions, created counseling centers and set up confidential Web sites and hot lines; others have developed elective courses in meditation and mindfulness, switched from letter grades to pass-fail systems and revamped class schedules to foster better work-life balance.

Despite the good intentions, their efforts continue to be stymied by one thing: Students aren't participating. As one educator recently told me, "I keep seeing the same 10 students at all these events, and I'm not even sure they're the ones we need to be reaching."

But one medical school, Vanderbilt, in Nashville, appears to be succeeding, with a Student Wellness Program that includes activities like yoga classes, community service events, healthy cooking classes, forums on nutrition and sleep, and a mentoring program that pairs senior students with newer ones. The key to its success? Empowering and partnering with those who have the most at stake — the medical students themselves.

Aside from an annual daylong retreat and a weekly medical humanities course, "most of the ideas are generated by the students themselves," said Dr. Scott M. Rodgers, the associate dean of medical student affairs, who started the program with a group of students six years ago and continues to be its guiding force. "We just try to come up with any necessary money."

One example of this unique collaboration is the program's college system, which assigns students to one of four "colleges," each with its own set of faculty advisers. Instituted nearly five years ago and intended simply as an improvement over a traditional but more random advising program, the new system was also set up in a way that allowed Vanderbilt students to introduce innovations.

They ran with it. Drawing on cultural cues that resonated with their peers — in this case the Harry Potter stories — they took an active role in naming the colleges after former medical school deans and imbued each with a particular personality. Completing the picture were artfully designed crests, designated college colors and devised mottos in Latin that range from the more noble ("Primus Inter Pares," or "First Among Equals") to the tongue-in-cheek put-down ("Commodum Habitus Es," or "You Have Just Been Owned").

As college loyalties began to develop, students organized friendly competitions that promoted healthy habits and community service. These events culminated four years ago in the first College Cup, a now annual weekend affair where pride runs deep. Amid bagpipes and a marching band, colleges vie to outdo one another in events like a 5-K run, an "Iron Chef"-style cooking competition and a trivia contest.

"These programs keep you from putting your whole self-worth on the next exam," said Kathleen Weber, a first-year student who was also quick to point out the superiority of her own college, Batson.

There are critics, however, who charge that with so much to learn in so little time, medical students — and their future patients — would be better served if they expended more, not less, effort on studies. Others have voiced concern that students end up feeling a "reverse pressure" to choose extracurricular activities over studying.

But proponents are quick to counter that medical students in general aren't people who must be persuaded to study. What they need is encouragement to balance academic dedication with the self-care that will sustain them in the long run. "You can't keep running on fumes," said Dr. Johanna N. Riesel, a former medical student at Vanderbilt now in her second year of surgical training at Massachusetts General Hospital in Boston. "You have to learn how to maintain some sense of equilibrium and sanity in a relatively insane process."

While no one yet knows the long-term effect of Vanderbilt's innovations – or, for that matter, of any programs designed to promote "wellness" — Dr. Rodgers and his colleagues and students at Vanderbilt remain committed to their initiatives. For them, the implications of medical student depression and burnout are simply too important to ignore.

"It's a challenge for anyone to stay healthy and happy," Dr. Rodgers said. "But when doctors are able to stay healthy and happy, that means patients get physicians who are more compassionate and selfless. They end up with doctors who really have the energy to invest time in them."

Tuesday, December 20, 2011

Close to Home

As Patient Records Are Digitized, Data Breaches Are on the Rise -

One afternoon last spring, Micky Tripathi received a panicked call from an employee. Someone had broken into his car and stolen his briefcase and company laptop along with it.

So began a nightmare that cost Mr. Tripathi's small nonprofit health consultancy nearly $300,000 in legal, private investigation, credit monitoring and media consultancy fees. Not to mention 600 hours dealing with the fallout and the intangible cost of repairing the reputational damage that followed.

Mr. Tripathi's nonprofit, the Massachusetts eHealth Collaborative in Waltham, Mass., works with doctors and hospitals to help digitize their patient records. His employee's stolen laptop contained unencrypted records for some 13,687 patients — each record containing some combination of a patient's name, Social Security number, birth date, contact information and insurance information — an identity theft gold mine.

His experience was hardly uncommon. As part of the 2009 stimulus bill, the federal government provides incentive payments to doctors and hospitals to adopt electronic health records. Some 57 percent of office-based physicians now use electronic health records, a 12 percent jump from last year, according to the Centers for Disease Control.

An unintended consequence is that as patient records have been digitized, health data breaches have surged. The number of reported breaches is up 32 percent this year from last year, according to the Ponemon Institute, a security research group. Those breaches cost the industry an estimated $6.5 billion last year. In almost half the cases, a lost or stolen phone or personal computer was responsible.

In a blog post, Mr. Tripathi describes the days after the theft as a "vortex." Fresh in his mind was a similar, albeit smaller, breach at Massachusetts General Hospital just months earlier in which a hospital employee left detailed clinical records for 192 patients on a subway. The breach had cost the hospital $1 million in settlement fees.

"We're a nonprofit with 35 people on staff," says Mr. Tripathi. "A million-dollar fine would have decimated us."

Mr. Tripathi says his nonprofit had just enacted a policy requiring that all patient files be encrypted, but had yet to decide on an encryption provider. All that stood between a determined computer thief and his patient data was a few passwords.

Mr. Tripathi went to work assembling a crisis team of lawyers and customers and a chief security officer. They hired a private investigator to scour local pawnshops and Craigslist for the stolen laptop. The biggest headache, he says, was deciphering how much about the breach his nonprofit needed to disclose.

Health organizations are required by federal law to report data breaches that affect more than 500 people to the Department of Health and Human Services. The department's Office of Civil Rights publishes the equivalent of a data breach "Wall of Shame" on its Web site — which today includes 380 breaches affecting more than 18 million people.

Mr. Tripathi said he quickly discovered just how many ways there were to count to 500. The law requires disclosure only in cases that "pose a significant risk of financial, reputational or other harm to the individual affected." His team spent hours poring over a backup of the stolen laptop files. Of the nearly 14,000 patient records on the stolen laptop, most records did not warrant disclosure. In 2,777 cases, for instance, a record listed only a patient's name.

Complicating matters were liability rules. In the eyes of the law, Mr. Tripathi's nonprofit is a contractor that acts on behalf of health providers. The legal burden of protecting patient data actually falls on his clients: the physicians and hospitals who entrusted his nonprofit with their files.

"The laws create a perverse outcome," he says. "It was our fault, but from a federal perspective, it wasn't our breach."

Mr. Tripathi narrowed down the group of patients whose data put them at serious risk for identity theft to 998 people across seven physician practices. Only one practice broke the 500-patient threshold requiring disclosure on the Department of Health and Human Services Web site.

His office got to work notifying the affected patients of the data breach. They offered free credit monitoring — though less than 10 percent took them up on the option — spending a total of $6,000.

In the aftermath, Mr. Tripathi says his company destroyed all patient data on mobile devices and temporarily prohibited employees from removing patient data from clients' offices. The company now mandates that all data be encrypted, and employees are required to tell health providers what data they will need to access and how they plan to use it.

He never found the stolen laptop, and the incident, all told, cost his nonprofit $288,000.

In many ways, Massachusetts eHealth Collaborative got off easy. In October, a desktop computer containing unencrypted records on more than four million patients was stolen from Sutter Health, a nonprofit health system based in Sacramento. A rock was thrown through a window to gain access to the computer. The theft is now the subject of two class-action suits, each of which seeks $1,000 for each patient record breached.

"Breaches are going to be one of the big challenges as more physicians and hospitals adopt electronic health records," Mr. Tripathi says. "We're entering a brave new world."

Sunday, December 18, 2011

Should dentists offer health screenings? – - Blogs

Each year, nearly 20 million men, women and children in the United States fail to see a family physician or similar health care professional, but they do pay at least one visit to the dentist, according to a new study in the American Journal of Public Health.

For this segment of the population, dentists may be the only doctors in a position to spot the warning signs of chronic illnesses, such as diabetes, and provide referrals or advice to prevent serious complications, says Shiela M. Strauss, Ph.D., the lead author of the study and an associate professor at New York University's Colleges of Dentistry and Nursing.

Oral or dental abnormalities can signal a broad range of body-wide health problems, including HIV, sexually transmitted diseases, eating disorders, and substance abuse, in addition to diabetes. In a previous study, for instance, Strauss and her colleagues found that 93% of patients with gum disease (such as gingivitis) also met the criteria that should trigger blood-sugar screening under American Diabetes Association guidelines.

"I'm not advocating for dentists to become general health care providers," Strauss says. But, she adds, dentists can easily measure blood pressure and administer simple screening questionnaires - both of which could potentially make a big difference to the health of someone at risk for diabetes who hasn't seen a doctor recently.

In the new study, Strauss and her team analyzed data from the Medical Expenditure Panel Survey, a nationally representative government-sponsored survey of health care use. In 2008, the researchers found, roughly one-quarter of adults did not see a physician, nurse practitioner, or other general health care provider - but of that group, 23% did see a dentist. The pattern was similar among children.

It's not clear what's leading these people to see a dentist but skip medical care. Most of the adults - and nearly all of the kids - had health insurance, so lack of coverage can't fully explain it. In fact, the authors note, the dentist-only group was "quite diverse" ethnically, socioeconomically and geographically.

It could be that dental problems - unlike some chronic diseases - are often too painful to ignore, Strauss says, or it could be that dentists are simply better than doctors at reminding patients when it's time for a checkup.

Getting dentists in the habit of screening for health conditions will probably require changes to dental-school curricula, the researchers say. However, dentists and dental hygienists are typically already trained to check blood pressure and conduct other types of general medical screening.

And while they might be hesitant to take on more patient responsibilities, Strauss says, doing so may have unexpected benefits. She points to the experience of some Swedish dentists who participated in an insurance plan that required them to implement diabetes screening for their patients.

"The reputation got out there that these were dentists that really cared about the patients," she says. "It was an initial investment of a bit more time on the part of the dentist, but it reaped great rewards for them in terms of growing their practice."