Category: Doctors & Hospitals

Prostate Cancer — Does Everyone Need Treatment?

By Mark A. Kelley, MD |09/20/16

Last week, the New England Journal of Medicine published an important study about prostate cancer. The research showed that men with early stage prostate cancer can safely choose “monitoring” instead of treatment.

This might seem like a strange recommendation for such a serious disease. However, prostate cancer is an unusual malignancy. It is more common as men age but it rarely causes death.

Prostate cancer can be detected very early with the simple blood test, the prostate-specific antigen (PSA). The treatment is either surgically removing the prostate gland or treating the prostate area with external radiation. Both treatments are effective but can cause impotence and incontinence.

This is an unusual paradox in cancer treatment. A very simple blood test can detect prostate cancer in its early stages but the cancer grows slowly and is rarely fatal. Furthermore, the treatments have important side effects. Should a patient undergo treatment for a cancer that is rarely causes death?

The new study helps to answer that question. The major goal was to determine if prostate-cancer survival is better with early treatment versus to a “watch and wait” strategy. The study recruited over 1600 men between 50-70 years old with localized, early stage prostate cancer. These volunteers were randomly assigned equally to one of three groups: immediate surgery; immediate radiation; or “active monitoring” of their cancer by a medical specialist. During that monitoring, patients whose cancer became more aggressive were offered treatment. All patients, on average, were followed for ten years.

The major results of this study are:

1.  For all patients with localized prostate cancer, the 10-year survival from the disease was 99%.

2. There was no survival advantage from early treatment or the type of treatment (surgery vs. radiation).

3. Progression of prostate cancer occurred in 20% of the “active monitoring group” and in less than 10% in the treatment groups. This difference did not have any affect on survival over the ten years of the study.

4. About 60% of the “active monitoring group” eventually had surgery or radiation during the follow-up period. However, the remaining 40% had no progression of their disease.

What did we learn from this study?

The study confirms that localized prostate cancer does not behave aggressively. Over ten years, survival is excellent. Nearly half of the patents assigned to follow-up had no progression of their disease. They were spared unnecessary procedures. This lends support to follow-up as an option for patients.

What still remains in question?

More of the “active monitoring” patients had progression of their cancer compared to early treatment patients. (20 % vs. 10 %). This difference did not affect mortality in this study. However, the significance of this finding is unknown and warrants further research.

What will physicians recommend now?

Before this study was published, most experts have been offering follow-up as an option for men with localized prostate cancer. This new study gives convincing evidence that follow-up, instead of immediate treatment, can be a safe choice for newly diagnosed prostate cancer patients. In 40% of such patients, the tumor remains stable over a decade and requires no treatment. If the tumor grows during that period, and treatment is needed, the survival rate is still 99%.

A warning: in this study, specialists carefully followed men with “active monitoring”. Men who do not have this follow-up may have less favorable results.

This study may be especially helpful for patients who are hesitant about treatment. Those concerns are often about the complications of treatment or the risks of co-existing medical conditions. For such men, this study confirms that monitoring is a reasonable choice. This information will make it easier for doctor and patient to plan the next steps.

This is a great example of how medical research can help patients make informed choices.

To read more about prostate cancer, see the American Cancer Society website.


What is Precision Medicine?

By Mark A. Kelley, MD |08/01/16

In his State of Union address this year, President Obama announced a federally funded program called ”Precision Medicine”. This $215M project is designed to improve disease treatment and prevention by studying the variability in genes, the environment, and lifestyle for each person. A “cohort” of one million volunteers from different parts of the nation will followed over a number of years.

This project resembles the famous Framingham Heart Study, which began almost 70 years ago. That study has provided major insights into the causes of heart disease by following patients over many decades.

In this era, we have many more tools to improve our understanding of how diseases evolve over time. We can track massive amounts of information about patients and analyze their genes. We also have new electronic communication and monitoring tools. The hope is that we can find better ways of prevention, detection and cure of diseases. Already, medical research is facing some important challenges. Here are several examples.

Inherited disease is more complicated that we thought. Medical science has achieved major breakthroughs in understanding how the human genome behaves. Genes control most of the processes in our bodies and slight changes in those genes can cause problems. Some inherited genes have been known for decades – such as sickle cell disease and cystic fibrosis. However, the system is much more complex than ever imaged. Only recently have we begun to understand how inherited genes cause disease.

Genes can control our response to prescribed drugs. Some drugs, such as those for conditions like hypertension and blood clots do not work the same for everyone. Many patients may need higher (or lower doses) and for some, the drug does not work at all. Research suggests that these variances may be due to different genes that control the way the drug interacts with our bodies. How do we know which drugs are best for each person? Should we test everyone for genes that control response to prescribed drugs?

Genes can become abnormal and trigger disease. Curing cancer is at the core of the Precision Medicine project. All cancer is from the uncontrolled growth of cells. In many cancers, genes that control cell growth no longer work normally and the result is a tumor. We do not understand how or why this happens. In some cases, genetic analysis of the patient’s tumor reveals which genes are defective and therapy can be developed to block the effects of these abnormal genes. The influence of genes on human disease is the hottest area of medical research. Precision Medicine will help us understand much more about these processes.

How are diseases related to the environment, including social factors? We know much about toxins and other environmental risks but we need to learn more. The influence of social factors on health is not well understood. Poverty, education, and life style can affect health but the details are lacking. For example, is poverty a risk factor for hypertension when you exclude all other factors except poverty itself?

Fortunately, we have the tools to improve our understanding of these issues. Studying the human gene has become very sophisticated and less expensive. With this technology, we may learn how and when genetic testing is useful in a large population. Supercomputers can analyze enormous volumes of information about patients over many years. This may reveal important clues on disease patterns and risks for individual patients.

We in the United States are a very diverse population and each of us is uniquely different. With Precision Medicine, we may better understand how to provide the best care for every individual.

For more information about Precision Medicine, go to the National Institutes of Health website or the White House webpage.

If you are interested in enrolling in the project, contact the NIH Precision Medicine participation website.

Does Your Physician Know What You Pay for Healthcare?

By Mark A. Kelley, MD |07/05/16

All of us should understand our own health care costs. However, as we have discussed here before, the issues can be complicated: e.g. insurance premiums, deductibles, co-pays, etc.

Physicians have a different perspective. Like any professional, they focus on how they are paid. Insurance companies require doctors to submit many details with their bills. Physicians rely on sophisticated billing systems to furnish that information, because without it, they are not paid. In a nutshell, patients worry about paying the bills and doctors worry about sending out the bills.

This raises a key question. How much do doctors know about your insurance and what you must pay?

Of course, the doctor can explain his/her own bills to you. Your doctor’s office has checked your insurance and knows how they should bill your insurance company.   Surprisingly, the doctor may not know much your hospital insurance coverage, or your deductible. Most physicians and their staffs have not been trained to gather this information because it does not affect physician payment.

But things have changed. With high deductible insurance plans, patients have more risk for out-of-pocket costs. A blood test, x-ray, or medication can come with a large bill if it drops into your deductible.

The prices may astound you. A friend recently enrolled in a high deductible insurance plan. She refilled prescription, which previously cost her $40 co-pay. With her new insurance, she had to pay $250 for the same refill because it was part of her deductible. The price was so high because the insurance company passed all the drug cost on to her.

Why is this important?   It is wise to know what you are paying for — and health care is no exception. Health care bills can mount quickly and squeeze the family budget. Sometimes, families face the tough choice of either paying the rent or seeing the doctor.

Physicians are seeing more of their patients struggling with health care bills. This pressure may discourage them from seeking medical care. Tight finances are becoming a health care risk, even for families with decent incomes.

How can patients and doctors work together to control the “costs of care”?

Here are a few suggestions:

1. Know the details of your own insurance policy, especially “out-of-pocket costs”such as co-pays, coinsurance and deductibles. If you have any questions or concerns, contact your insurance company.

2. When your doctor recommends a test, procedure, or treatment, make sure you know what it involves, why you need it, how effective it will be and how soon it must happen. These are questions that any good doctor would be glad to answer.  The timing of the test or procedure may be important if you have already paid out your deductible before the end of the year. In that case, you may not have to pay anything for the service.

3. Cost may (or may not) influence your decision to get a test or procedure. For example, for an urgent life-saving procedure, cost may not even enter your mind. However, some tests or procedures may not be so convincing. In those cases, cost might influence your decision. If so, discuss the cost issue with your doctor who may suggest less expensive alternatives. The timing, location and type of service may all influence the cost: most often for planned (elective) procedures, x-rays, or some medications.

4. If health costs worry you, talk to your doctor. Don’t be afraid to bring up the issue. You are not alone. Many more patients are asking about costs these days. Physicians welcome solving these challenges with you. They can be very helpful if they understand your concerns.

Learn how physicians are addressing this problem on the website Costs of Care.

Choosing a Physician

By Mark A. Kelley, MD |06/27/16

Choosing the right physician is an important step.

First, let’s review a few definitions. All doctors are trained in a specialty like internal medicine, pediatrics or surgery. We term these doctors “specialists”. Beyond their specialty, some doctors have advanced training in fields such as cardiology, plastic surgery, pediatric intensive care, etc. These doctors are “sub-specialists”.

Here are some things to consider when choosing a physician:

1. What kind of doctor are you looking for?

Primary Care – If you want a doctor who can treat most common illnesses, a primary care physician is a good choice. These physicians are specialists in internal medicine, family medicine or (for children) pediatrics. You want your doctor to be nearby if you are sick. Therefore, most people prefer that their primary care physician be convenient to their home. Usually that doctor also has staff privileges at your local hospital.

Sub-specialty Care – (like joint surgery, cardiology) – most hospitals have sub-specialists in both surgery and medical fields. Your primary care physician will know them in your community and you can also ask around as suggested above. Be aware that some sub-specialists will only see patients referred by another physician.

What Most People Do: Choosing a primary care physician is good first step. He/she will get to know you personally and understand your needs. Shopping around for a sub-specialist for every problem is unnecessary if you have a good primary care physician. That doctor can handle most common conditions and will also refer you to a subspecialty expert if necessary. For recommendations about specific doctors, it can be helpful to ask friends (particularly those in health care).

2. How can you judge the quality of the doctor?

Finding information about physicians is easy, thanks to the Internet.

Finding the Doctor’s Practice Site – You can perform an online search for the doctor by name and find their office location and other details. Be sure to add the doctor’s degree to their name (usually “M.D.” or “D.O.”)

Credentials – all doctors have the same credentials: medical school, specialty training (residency), medical license and, in most cases, specialty board certification. You can find this information from their hospital’s website, the doctor’s practice website or from national listings.

Public Quality Reporting – there are ratings of physicians’ quality that come from the federal government. These reports are still under development and most experts feel that they are not yet very precise.

“Best Doctors” Ratings – some commercial companies publish listings of the “best doctors” in a region or across the nation, often for a subscription fee. These ratings concentrate on sub-specialists and are usually based on physician polling. These sources can vary in quality and consistency. In addition, many excellent doctors are not listed in these directories.

Consumer Ratings – consumers are now rating doctors through websites such as “Yelp”. This new movement is gaining some traction with consumers. Most of the feedback is focused on the doctor’s bedside manner and how the practice is organized. This is helpful in judging the “user-friendliness” of the practice. However, these ratings may not be reliable in judging the clinical skill of the physicians.

The Physician’s Professional Experience – As with all professions, experience matters in medicine. However, there are other issues to consider. A new physician may be more available and also more up-to-date in the latest medical advances. A senior physician who practices only part-time may not have as much experience as a younger colleague who practices full-time. Regardless of age, physicians who perform surgeries and other procedures must perform them regularly to maintain their skills.

What Most People Do: The most trusted source of information about a doctor still comes from a physician or a relative/friend. However, many folks will also check on the physician’s background from the online sources above. When you select a physician, ask the him/her about their experience, particularly in performing procedures. One rule of thumb: a practicing physician is usually good at what they are do now—not what they did years ago.

3. How can I see an expert at a famous medical center?

Most large medical centers are teaching hospitals with multiple missions: providing medical care, educating future physicians, and performing medical research.
Often, these hospitals are owned or affiliated with a university. This allows them to recruit experts in complex and challenging medical conditions.

Seeing such an expert may not be difficult. Many centers are open to self-referred patients although some still require a referral from your doctor. A good approach is to look at the hospital’s website and find the “How to Make and Appointment” section.

What Most people Do: – The process is easier if you use your own physician to recommend and orchestrate the referral. Sub-specialists at large centers are more likely to expedite physician referrals from physicians. With your permission your doctor will send your records to the medical center expert and help coordinate your care.

4. How do I know the doctor accepts my insurance?

Doctors accept most insurance plans but you should check the details. If you are looking for doctors who accept your insurance, contact your insurance company–either by phone or on their website. Most companies list their participating doctors on their website or in a printed directory

Once you select a physician, it is best to verify the insurance information by calling the doctor’s office. You do not want any surprises when you arrive at your appointment.

As noted in a previous blog, check to see if you insurance includes a “narrow network”. This means that you must see doctors within that network. If you get treated “out-of-network” you may have to pay extra charges out-of-pocket.

Some of these networks have a limited number of doctors and hospitals you can use. Others are “wider”, with more options. Your insurance company can provide this information.

Health Web Navigator