Was this mastectomy necessary? It’s a question few breast cancer survivors want to ask, and one that few are likely to answer absolutely. But after years of aggressive emphasis on early diagnosis and treatment, some previous imperatives are being called into question. Noting that breast biopsy has long been considered the “gold standard,” a report in today’s New York Times addresses the new rethinking:
As it turns out, diagnosing the earliest stage of breast cancer can be surprisingly difficult, prone to both outright error and case-by-case disagreement over whether a cluster of cells is benign or malignant, according to an examination of breast cancer cases by The New York Times.
Advances in mammography and other imaging technology over the past 30 years have meant that pathologists must render opinions on ever smaller breast lesions, some the size of a few grains of salt. Discerning the difference between some benign lesions and early stage breast cancer is a particularly challenging area of pathology, according to medical records and interviews with doctors and patients.
Diagnosing D.C.I.S. “is a 30-year history of confusion, differences of opinion and under- and overtreatment,” said Dr. Shahla Masood, the head of pathology at the University of Florida College of Medicine in Jacksonville. “There are studies that show that diagnosing these borderline breast lesions occasionally comes down to the flip of a coin.”
Much of the current finger-pointing is toward pathologists, where their money comes from, whether they are ‘certified’ or not and in general, how good a job they do.
In 2006, Susan G. Komen for the Cure, an influential breast cancer survivors’ organization, released a startling study. It estimated that in 90,000 cases, women who receive a diagnosis of D.C.I.S. or invasive breast cancer either did not have the disease or their pathologist made another error that resulted in incorrect treatment.
After the Komen report, the College of American Pathologists announced several steps to improve breast cancer diagnosis, including the certification program for pathologists.
For the medical community, the Komen findings were not surprising, since the risk of misdiagnosis had been widely written about in medical literature. One study in 2002, by doctors at Northwestern University Medical Center, reviewed the pathology in 340 breast cancer cases and found that 7.8 percent of them had errors serious enough to change plans for surgery.
This space has argued occasionally for reconsideration of yearly mammograms and for longer, stronger consideration of other options before a mastectomy is performed. Especially in the case of older women.
Would I insist on further studies or opt for less radical treatment if I were diagnosed with breast cancer today? Probably. Can I undo the mastectomy I had at 72? Not exactly. Second-guessing is beside the point for someone who is healthy and fit, but asking questions won’t ever hurt.
New York City seems to be all aglow in being named by the World Health Organization to its Global Network of Age-friendly cities. As Clyde Haberman reported about the event in the July 1 New York Times,
“It makes us members of a club of people who are struggling, in their own and perhaps much different ways, with learning about and thinking about and approaching this issue,” said Linda I. Gibbs, the deputy mayor for health and human services. “It’s really a lovely recognition.”
One reason for the acknowledgment was a plan that city officials and the New York Academy of Medicine announced last year to improve life for older New Yorkers. All sorts of ideas were put forth, on matters like transportation, housing, health care, job training, nutrition and cultural activities. To a large degree, it was more a wish list than a concrete program. But at least it showed that the city was thinking about issues that will only become more dominant.
Like other cities, New York has a population that is aging, if you will forgive a somewhat meaningless word that we are stuck with. After all, everyone is aging. It’s called living. The only people not aging are dead.
WHO says, of its Global Nework of Age-friendly Cities, that the problem lies with the fact that too many of us are aging and not dying.
Populations in almost every corner of the world are growing older. The greatest changes are occurring in less-developed countries. By 2050, it is estimated that 80% of the expected 2 billion people aged 60 years or over will live in low or middle income countries. The Network aims to help cities create urban environments that allow older people to remain active and healthy participants in society.
To that end, the Network got off the ground a few years ago, and now lists a few cities across the globe as having been accepted for membership. This week’s bulletin (excerpted above and below) lists the Big Apple as the first U.S. member, although the PDF of member cities also lists Portland, and one has to wonder how Portland’s going to feel about all of New York’s hoopla.
The WHO Age-friendly Cities initiative began in 2006 by identifying the key elements of the urban environment that support active and healthy ageing. Research from 33 cities, confirmed the importance for older people of access to public transport, outdoor spaces and buildings, as well as the need for appropriate housing, community support and health services. But it also highlighted the need to foster the connections that allow older people to be active participants in society, to overcome ageism and to provide greater opportunities for civic participation and employment.
The Global Network builds on these principles but takes them a significant step further by requiring participating cities to commence an ongoing process of assessment and implementation. Network members are committed to taking active steps to creating a better environment for their older residents.
A few years ago (2006) the Sperling’s Best Places people came out with a “Best Cities” list about which do the best job of caring for their aging folks. The “Best Cities for Seniors” study examined the state of senior care in the 50 largest metropolitan areas in the United States.
“This is different from the usual studies of retirement living,” said Bert Sperling, the study’s primary author. “When we first retire, we have the energy for traveling and sightseeing. At some point, we will all need specialized resources and facilities to help us cope with aging. That’s what this study examines.”
This unique new study, produced in partnership with Bankers Life and Casualty Company, identifies cities that offer the best resources for less active seniors. The study analyzed nearly 50 categories such as various senior living facilities, comprehensive medical care, specialized transportation services, and a significant senior population.
Top Ten Cities for Seniors
- Portland, OR
- Seattle, WA
- San Francisco, CA
- Pittsburgh, PA
- Milwaukee, WI
- Philadelphia, PA
- New York, NY
- Boston, MA
- Cincinnati, OH
- Chicago, IL
Haberman takes issue with that ‘Senior’ word along with the ‘aging’ word. “What does that make the rest of the populace — juniors?” This space (an unabashed fan of Sperling’s #3 city — sorry, #7; but you’re my #2) concurs. But Great Geezer Towns probably wouldn’t cut it with WHO.
Is there a fate worse than death? Yes. In the U.S., often it is the fate of dying slowly: aggressively treated, over-treated and worn down by the system until that fate has made death truly a blessed relief.
Deborah Wright, an ordained Presbyterian minister and writer now working in secular fields while simultaneously serving as personal pastor to many, forwarded an article that proves out the fate-worse-than-death highlighted in this and recent other articles (see June 25 post below.) The fact that stands out, she comments, is that “the length of time we use palliative care services is growing shorter — because we start it too late.”
We start palliative care too late, we treat too aggressively and too long. The opening story in AP writer Marilynn Marchione’s thoughtful, poignant article just published in Daily Finance serves as a classic example:
The doctors finally let Rosaria Vandenberg go home.
For the first time in months, she was able to touch her 2-year-old daughter who had been afraid of the tubes and machines in the hospital. The little girl climbed up onto her mother’s bed, surrounded by family photos, toys and the comfort of home. They shared one last tender moment together before Vandenberg slipped back into unconsciousness.
Vandenberg, 32, died the next day.
That precious time at home could have come sooner if the family had known how to talk about alternatives to aggressive treatment, said Vandenberg’s sister-in-law, Alexandra Drane.
Instead, Vandenberg, a pharmacist in Franklin, Mass., had endured two surgeries, chemotherapy and radiation for an incurable brain tumor before she died in July 2004.
“We would have had a very different discussion about that second surgery and chemotherapy. We might have just taken her home and stuck her in a beautiful chair outside under the sun and let her gorgeous little daughter play around her — not just torture her” in the hospital, Drane said.
Marchione tells other stories of patients who might have had far more peaceful final days — and of patients who chose extensive, aggressive or experimental treatment for a variety of reasons. It should be the individual’s choice. But the reality is that discussion of palliative care or hospice care (there is a difference: hospice involves declining further treatment; with the newer “palliative care” concept some therapies may be continued) simply doesn’t happen until too late. If it happened sooner, many of us — likely including Rosaria Vandenberg — would choose hospice care over aggressive end-of-life treatment. But physicians are too busy talking treatment, and patients have not considered their other choices. Comfort and peace lose to the system.
An article posted today on the website of the National Hospice and Palliative Care Organization points the finger in the right direction, right at you and me. If we took the time and energy to write our advance directives, and talk them over with family and friends, millions of days of suffering and millions of wasted dollars would be saved.
Recent media coverage on the challenges patients and families face with overtreatment of a life-limiting illness brings the issues of hospice and palliative care and advance care planning to public attention.
“It’s important to remember that quality of life and a patient’s personal wishes, beliefs and values must be a factor when making care decisions brought about by a serious or terminal illness,” said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization.
“Discussions helping patients and families understand the many benefits of hospice and palliative care must be more common and held long before a family faces a medical crisis,” Schumacher added.
Advance care planning—which includes completing a living will and appointing a healthcare proxy—is somewhat like planning a road trip to an unfamiliar destination. Very few people would expect to get to a destination safely and comfortably without having a well-thought-out map in hand. Yet, it’s estimated that 70 percent of Americans have not completed a living will.
- A living will charts the course for your healthcare, letting your family and health care providers know what procedures and treatments you would want provided to you—and under what conditions.
- A healthcare proxy or healthcare power of attorney form, allows you to choose someone you trust to take charge of your healthcare decisions in case you are unable to make those decisions yourself.
- Advance directives can be changed as an individual’s situation or wishes change.
Still, you and I put it off. Or you may be putting it off, at least, and if so you are taking an absurdly unnecessary risk. You could, instead, download free forms, fill them out and avoid that risk.
Deborah Wright has shepherded countless friends and family members through their final days, and knows what a blessing hospice and palliative care can be. Problem is, though, “we start it too late.”
Can we have a functional, effective transportation system in the U.S.? Can we afford not to? Those were the questions addressed by former Secretary of Transportation Norman Mineta and a panel of experts at a full-house 9 AM event at San Francisco’s Commonwealth Club Friday. Oh — and how are we going to pay for it all? The program was titled “Funding the Transportation System of the Future.”
“Within the next two decades,” Mineta said in his introductory remarks, “the Census Bureau estimates that the U.S. population will increase by as many as 50 million people. This population growth, combined with a growing backlog of overdue maintenance work on roads and transit systems, creates a need for significantly expanded transportation revenues. However, the current political climate is generally unfavorable to tax increases.”
The ensuing discussion continually returned to two general points: first, that our parents and grandparents funded the transit infrastructures and systems we now enjoy and it is incumbent upon us to do the same for our children and grandchildren; and second, as Mineta and others repeatedly said, that there is no political will anywhere to do the latter. One illustration of the first point was cited by panelist William Millar, president of the American Public Transportation Association, who observed that “the New York subway system was built 106 years ago for $35 million — and you couldn’t get a feasibility study today for $35 million.”
Given the fact that most cities and counties could spend $35 million on overdue maintenance alone, most panelist comments and audience questions concerned the issue of finding funds at a time when tax increases are not very popular. “Creative funding” solutions appear to be the answer, even if there is currently far more creativity around than funds.
Asha Weinstein Agrawal, Director of the Mineta Transportation Institute‘s National Transportation Finance Center, cited a public opinion poll released yesterday (“one of those phone calls at dinner time…”) that surveyed 1500 people in English and Spanish to test receptiveness to eight variations of a possible gasoline tax. In general, opposition to such a tax is high, she said, but acceptance increases in proportion to benefits which individuals can see: tie the tax to emissions per vehicle and thus reduce greenhouse gases, for example. Agrawal recommended consideration of taxes linked to environmental effects.
Panelist John Horsley, Executive Director of the American Association of State Highway and Transportation Officials, said that because of funding cuts and declining revenues (from road usage fees etc), the U.S. Highway Fund will be insolvent some time between August and October of 2011, with the resultant loss of approximately 1 million jobs. He cited a few bright spots such as several states going ahead with high speed rail projects, “four states have actually raised gas taxes, Kansas has increased the sales tax, and New Hampshire sold itself a bridge” (which will get paid off through tolls.) High occupancy toll lanes were another potential funding source Horsley said could help until “fiscal sanity returns: investing in something good (rather than) borrowing forever.”
The consensus was aptly covered in one summation by California Senator Alan Lowenthal: “It’s a very difficult time for transportation.”
Whereupon this reporter got back on the #1 California Muni bus (catch a back seat, work on your computer for 30 minutes, no parking fee, no traffic hassle) and went home.
“We have to get out of the way,” she said; “make room for other, new people on the planet.” Accomplished author/editor Cyra McFadden, at a recent dinner party, was talking about a group of women scientist friends’ excitement over discoveries they have made which show promise of extending life a fraction longer. Cyra was in fierce, though silent, disagreement.
It may be time for those of us who disagree with the rampant prolong-life-at-all-costs theories to stop being silent.
Americans are, in fact (as reported in Epoch Times below, and elsewhere) living longer all the time. Sometimes that’s just fine, especially if we’re in reasonable health. But what if we’re not? What if we’d just as soon be getting on with whatever follows this temporary time on earth? Millions and millions of people are living for hours, days or extended months and years in circumstances they would not choose simply because we have created a culture that says we must be kept alive no matter what.
Average life expectancy continues to increase, and today’s older Americans enjoy better health and financial security than any previous generation. Key trends are reported in “Older Americans 2008: Key Indicators of Well-Being,” a unique, comprehensive look at aging in the United States from the Federal Interagency Forum on Aging-Related Statistics.
“This report comes at a critical time,” according to Edward Sondik, Ph.D., director of the National Center for Health Statistics. “As the baby boomers age and America’s older population grows larger and more diverse, community leaders, policymakers, and researchers have an even greater need for reliable data to understand where older Americans stand today and what they may face tomorrow.”
Where do we stand right now? Well, the same source that says we’re living longer and enjoying better health and financial security (hmmmm on the financial security business) reveals that Americans are “engaging in regular leisure time physical activity” on these levels: ages 45-64: 30%; ages 75-84: 20%; geezers 85 and over: 10%. Hello? Better health and financial security, just no leisure time physical activity? Could it bear some relationship to obesity factors in the same data: 30+% for men, 40+% for women?
Does living well need to be assessed in the compulsion to live long? Why not? Everyone should have the right to live at whatever weight and whatever level of inaction he or she chooses. But the system is weighted toward keeping us alive under all conditions, and bucking the system is not easy. A poignant, wrenching tale of her father’s slow decline and death — and her mother’s refusal to go down that same path — was recently told by California writer/teacher Katy Butler in the New York Times Sunday Magazine.
Almost without their consent, Butler’s gifted, educated parents had their late years altered to match the system’s preferences:
They signed living wills and durable power-of-attorney documents for health care. My mother, who watched friends die slowly of cancer, had an underlined copy of the Hemlock Society’s “Final Exit” in her bookcase. Even so, I watched them lose control of their lives to a set of perverse financial incentives — for cardiologists, hospitals and especially the manufacturers of advanced medical devices — skewed to promote maximum treatment. At a point hard to precisely define, they stopped being beneficiaries of the war on sudden death and became its victims.
Given the limitless sources of victimization floating around, we should not have to add just-try-to-keep-them-alive-forever health care to the list.
My husband and I, having long ago signed advance directives with additional specific issues sheets (“If this happens, do that; if that happens, don’t do this,” etc) recently got them out and talked things over again, a very good thing to do for EVERYbody over 18. We will add dementia provisions to the existing documents while we can remember to do that (the closest you can come to avoid being warehoused in a memory-loss facility for umpteen years.) We are clear, and our friends and family understand, about having no interest in hanging onto life in a greatly diminished state if such an opportunity presents itself; for increasing thousands, it presents itself every day.
All this being said, there’s still a reasonable chance that I’ll be out of town one day when I’m in my 80s (which aren’t that far off), get wiped out by a speeding cyclist and picked up in a seriously mangled state by the paramedics, taken to a hospital that’s not Kaiser (which has all my directives on file,) miraculously brought into some heavily-sedated state of being because the hospital doesn’t consult Kaiser or the living will registry (which also has my directives) and kept alive by assorted mechanisms. By the time my husband or children get there to insist everything be unplugged — which of course will involve long hours and possibly court action — hundreds of thousands of dollars will have been needlessly spent.
I consider myself a highly valuable member of society, and my life a gift from God. But would those dollars not be better spent on a few kids needing specialized care?
Recently, someone remarked to Muhammad Yunus, the Bangladeshi banker/ economist/ crusader against poverty, that he must be a very rich man.
“I said, why would I be a rich man?” he tells an attentive audience. “Well, you have all those companies; you must be rich to have all those companies.” Yunus scratches his chin and smiles the beguiling smile that makes you want to be a believer. “Oh. I start these companies, but I would never own them.” You are now a believer.
Yunus was in San Francisco Monday, at a social entrepreneurship program sponsored by the Commonwealth Club. He is winding up a U.S. tour promoting his new book, Building Social Business: The New Kind of Capitalism That Serves Humanity’s Most Pressing Needs. In the process, he is promoting a theory that social business — business operated for the benefit of society (such as the poor who are commonly the beneficiaries and owners of Yunus’ companies) — can and should be a viable segment of the global economy.
Grameen Bank, which was begun in 1976 with $27 out of Yunus’ pocket and now provides loans to more than 8,100,000 borrowers — no collateral, just good faith and trust — would seem to prove his point. Defaults on Grameen micro loans are so few as to make Fannie Mae weep.
From micro loans, Yunus expanded into business ventures on the same basic principle: to achieve one or more social objectives through the operation of the company. The investors/owners can gradually recoup the money invested, but cannot take any dividend beyond that point.
There are now Grameen (the word refers to a rural village) companies in banking, agriculture, healthcare, telecommunications and other areas. Yunus gave one as an example of why he believes the principle works:
Grameen and Group Danone went into a joint venture to create a yogurt fortified with micro-nutrients to decrease malnutrition for the children of Bangladesh. The yogurt is produced with solar and bio gas energy and is served in environmentally friendly packaging. The first plant started production in Late 2006. The 10-year plan is to establish 50+ plants, create several hundred distribution jobs and self-degradable packaging.
The environment is protected, children get healthy, grow up to create businesses. Yunus spoke of one skeptic saying, “where will I get a job?” and said he explained, “You don’t look for a job, you create a job.”
Grameen Bank has more than 2500 branches — now including three in New York (where Yunus would like to see payday loan and check-cashing operations go out of business), one in Omaha, and in the near future: one in San Francisco. If Yunus is enjoying the proving out of his theories and the lifting of vast numbers of people out of poverty, he may be enjoying most of all the reminiscences about those who scoffed at his notions in the 1970s.
“They said the poor were not credit worthy,” he smiles. “I was told, about non-collateralized loans, ‘You can’t do that!’ After 2008, I wanted to ask, ‘Who is credit-worthy?'”