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Obamacare and Gun Screening

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The Affordable Care Act, more commonly known as Obamacare, was originally planned to contain a provision regarding gun violence screening and reporting by doctors. This was dropped, under pressure, from the act that was ultimately passed. In fact, language was specifically added, in a section called Title X, that specifically outlines restrictions on doctors to prevent them from recording and tracking gun violence statistics and the results of gun violence screening. Title X also states that healthcare programs may not require gun violence screening questions, and that patients may not be forced to answer gun violence screening questions.

Nevertheless, since the passage of the act, there have been a number of attention-grabbing headlines and chain e-mails of doctors demanding patients answer gun screening questions. Never mind the fact that your doctor cannot force you to answer anything, or that insurance companies cannot restrict their policies based on gun ownership or the likelihood of gun violence (it’s right there in the Affordable Care Act!).

Are these doctors overstepping their bounds? Are they breaking the law?

In a word: No.  None of the provisions in Title X can stop a physician or a patient wanting to discuss firearms violence or ask questions about threats of gun violence. Doctors are doing so because they believe it can save lives. We can’t write it down, and we can’t share the data, but we can work with an individual patient to determine if they are at risk and what steps they could take to protect themselves and the people they love.

Everyone seems to agree that mental health is an issue with regards to gun violence. We are trying to directly address this problem. We are not violating your rights, and anyone that tells you we are doing so is lying to you to fulfill their own agendas. When you go to a medical professional, our job is to determine the risks – ALL of the risks – that you might be facing to your life and well-being. For years, patients have been speaking to their doctors about their fear of gun violence in their homes – doctors have simply started asking in advance, because many patients are not aware this is something we can help them with.

When guns are present, people are more likely to die as a result of violence. Simply having a gun in the home makes homicide or suicide more likely. Americans have always owned guns, and likely will continue to do so. The only way for us to reduce gun violence is to look to the source: people who are at risk.

New Gun Violence measures taken by the White House

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With a number of stories in the news lately about toddlers and young children accidentally shooting, and sometimes killing, themselves and their family members with unlocked guns, President Obama has made a priority of putting new protections in place to help curb the gun violence epidemic that has infected our country.  These new protections focus primarily on the practical safety measures and better screening and reporting for mental illness, and are aimed to be less controversial than past attempts to reduce gun violence. We’ll take a look at the current measures being pursued and what they might mean.

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Smarter Handguns

The first and most well-known idea the administration is pushing is the use of smart-gun technology, designed to prevent people either than the gun owner from firing a handgun. The goal of this technology is to keep guns out of the wrong hands, prevent children from firing unlocked guns, and curb the illegal sale of firearms.

The current challenges facing this technology are largely practical: Are these guns equally effective in the hands of police and military personnel as current firearms? And can manufacturers be convinced to produce these new smart guns efficiently?

The administration hopes to answer these questions by running military tests and incentivizing both manufacturers and local governments from adopting smart gun technology.  A fully report on the processes being implemented can be found here.

While responsible gun owners have long touted the policy of “lock up your guns”, the government has now chosen to have a hand in making this more of a mandatory process than a friendly suggestion. While it may not solve the issue of legal gun owners committing violent crimes, it does provide a welcome safeguard against accidental violence and some amount of black market gun sales.

Focus on Mental Illness

Currently, laws do not allow doctors to collect or share data on gun violence, despite the fact that many doctors now choose to screen for gun violence with their patients. As a result, the president has focused on the background checks system as the current most important stage of screening. The proposed rule the administration is publishing is designed to ensure that mental health information is appropriately reported during background checks while attempting to obtain a firearm. It also seeks to provide an exemption policy from people with mental health issues that nevertheless seek to be cleared to own a firearm.

This policy change would still not fix the knowledge gap we have artificially created which prevents doctors from compiling gun violence records for study. Only by changing the laws in a significant manner could we do that, but heavy lobbying from the NRA has thus far been successful in preventing this from happening. Hopefully, myself and fellow medical professionals will one day be permitted to gather real, concrete data to better understand the gun violence problem we have as a nation, but for now steps like this may help staunch the bleeding.

State and Local Collaboration

This is the least concrete of the initiatives, as it simply announces a 50-state initiative to combat gun violence on the state and local level.  The 50-State Gun Violence Prevention Convening will focus on legislative and executive actions to fight gun violence, as well as a forum to discuss the current background system and reporting tools available to the states.

While it’s difficult to see significant change arising from this initiative, the current issues with reporting on gun violence and the background check system make things like this necessary to better understand the challenges faced at the state and local level.

There’s little doubt that the Obama administration has been frustrated by past attempts to fight gun violence in this country. This recent announcement reflects some of those frustrations, focusing instead on practical, less-controversial measures to fix what can be fixed. Let’s hope these small measures result in real change, and that this is the first step toward a country free of the fear of day-to-day gun violence.

Breast Cancer Screening and Prevention E-book Released!

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BreastCoverThis week marks the launch of our 2nd e-book in the Adult Guide: Health Screening and Prevention line: Breast Cancer Screening and Prevention! This book is much smaller than the original book, and focuses exclusively on breast cancer. It’s focused on boiling down as much information as possible into a set of need-to-know guidelines that can serve as your go-to source of information on fighting this deadly disease through preventive medicine.

When we released the original Health Screening and Prevention guide, we knew that most people would be far more interested in shorter, more focused book rather than the huge wealth of information present in the original. If you’ve already grabbed a copy of the original book, you’ve already got access to this information, along with a huge wealth of preventive tools for dealing with dozens of other common but potentially deadly ailments.

This book is for those who are looking for a simple, straightforward handbook that should explain the basics of breast cancer, mammography, positive and negative tests, and how to identify if you are high-risk for breast cancer. It also provides clear timelines so you know exactly when to talk to your doctor about testing and what the results might look like.

We’ll be releasing these “mini-e-books” for each of the major diseases covered in the big guide, and we’ll continue to update you here each time a new release goes live. Until then, we hope you find this guidebook to be useful in your own fight against breast cancer!

Frequently Asked Questions about Breast Cancer Screening

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While writing our recently released e-book on breast cancer screening, we spoke to a number of doctors about some of the most frequently asked questions they received from their patients. Many of them address popular myths about breast cancer; others were about the mammogram procedure itself, or about what happens after you get your result back. We’ve included some of these questions, and their answers, below.

  1. What is mammography?
  2. How accurate is mammography?
  3. How is it performed?
  4. What is the radiologist looking for?
  5. Can breast cancer be missed?
  6. Are there other screening options?
  7. Is it possible for my screening mammography to be normal and yet I may be harboring cancer?
  8. When do I start breast cancer screening?
  9. My mother and my aunt were diagnosed with breast cancer. When do I start breast cancer screening?
  10. Do insurance companies cover breast cancer screening?
  11. What is BRCA genetic testing?
  12. If I test positive for BRCA-1 or BRCA-2 mutation, what are my chances for developing breast cancer?
  13. I have a BRCA-1 mutation, what are my options?
  14. Can men get breast cancer?
  15. I have big breasts. I’ve been told that I will probably get breast cancer in the future. Is this correct?
  16. What is a sentinel lymph node?
  17. How do I prevent breast cancer?

What is mammography?

Mammography is an x-ray test to look at the inside of your breasts. It uses ionizing radiation to detect abnormal breast architecture and to evaluate for any abnormal lumps, lesions, tumors, mineralization, or signs of cancer.

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How accurate is mammography?

Mammography is able to detect very small lumps and lesions. It can detect a lesion as small as 1 mm. It is able to pick up lesions about two years before the physician can detect it clinically in the office during the routine physical examination. A lesion has to be about 10 mm before a physician can feel it.

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How is it performed?

The breast tissue is compressed against a plate. This may be uncomfortable but only lasts a few minutes. Compression is needed to accurately visualize all the breast tissue on the film. Four films of the breasts are taken from different angles by the radiology technician. The 4 images are then examined by a radiologist (MD, DO, or MBBS) trained in this field.

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What is the radiologist looking for?

The radiologist examines the films to assess for suspicious findings that may be consistent with cancer. The physician examines for lesions, masses, micro-calcifications, and distortion of the breast tissue architecture.

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Can breast cancer be missed?

Mammography is not 100 percent accurate. Yes, it can miss breast cancer, but it is the most widely available breast cancer screening test we have. It is also of note that the “axillary tail” is difficult to visualize on the films and may be missed. This is the part of your breasts that extends into the armpit. A mammography can also give a false-positive test. This means that the test comes back positive (something abnormal) even though you do not really have cancer.

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Are there other screening options?

The magnetic resonance imaging (MRI), digital mammography and positron emission tomography (PET) are in experimental stages of development. They are not yet available for routine breast screening. Ultrasound of the breast is performed after the patient has been found to have a lump or palpable mass during the physical examination.

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Is it possible for my screening mammography to be normal and yet I may be harboring cancer?

Yes, this is known as the false-negative test. This means that your mammography shows no evidence of cancer, lumps, or tumors, and yet you may have cancer in your breasts. This is very disturbing. This gives you the false sense of security. Younger women and women who have dense breasts have problems with false-negative tests. However, USPSTF states that it found no data that these false-negative tests led to any delay in the proper diagnosis of true breast cancer.

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When do I start breast cancer screening?

These are the recommendations. You may follow one of the two.
1. Begin at age 45 as recommended by the American Cancer Society.
2. Begin at age 50 as recommended by the US Preventive Services Task Force.
This is assuming you are average risk for breast cancer. The ACS recommends annual screening as long as the patient is in good health. The USPSTF recommends screening every two years and stopping at age 74.

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My mother and my aunt were diagnosed with breast cancer. When do I start breast cancer screening?

At a much earlier age depending on your risk factors. Your doctor will determine for you the age at which you should begin screening. Mammograms and MRI are used in some high risk individuals annually beginning at earlier age.

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Do insurance companies cover breast cancer screening?

Yes, all the insurance companies I know of cover most health screening including breast cancer. If your insurance company does not cover common types of screening procedures, I suggest you change your insurance company.

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What is BRCA genetic testing?

This is breast carcinoma (cancer) genetic blood testing to identify if you carry this marker of malignancy.

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If I test positive for BRCA-1 or BRCA-2 mutation, what are my chances for developing breast cancer?

If you test positive for BRCA-1 or BRCA-2 gene, your chances of developing breast cancer are very high by age 70. For Ashkenazi women, the chances of developing cancer range anywhere from 26 to 81 percent.

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I have a BRCA-1 mutation, what are my options?

For women who have either BRCA-1 or BRCA-2 mutation, the options are the following:
1. Intensive screening with MRI
2. Prophylactic mastectomy or oophorectomy
3. Chemo-prevention
Women who have a BRCA-1 mutation have estrogen receptor negative malignancy. BRCA-2 breast cancers are usually estrogen receptor positive. These women respond to tamoxifen with reduction in incidence of breast cancer.

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Can men get breast cancer?

Yes. Men do have some breast tissue under the nipples. One percent of all breast cancers occur in men. Roughly 500 cases of breast cancer are recorded in men each year in United States.

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I have big breasts. My friend told me that I will probably get breast cancer in the future. Is this true?

Your friend is misinformed. Large breasts do not increase your risk of getting breast cancer. However, large breasts often make it difficult to visualize breast cancer on mammography. This is because of dense tissue.

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What is a sentinel lymph node?

The sentinel lymph node is the first lymph node to which breast cancer will spread in a long chain of lymph nodes. This is a very important discovery because it allows surgeons to biopsy this node and assess if cancer has spread. The presence of cancer in this node means cancer has spread outside the breast.

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How do I prevent breast cancer?

Two preventive approaches are recommended in order to reduce the chances of getting breast cancer.
1. Obtain good health screening from your physician. Follow the recommended guidelines for the early detection of breast cancer as outlined in this book. Breast cancer screening begins at age 40 or 50.
2. Exercise and eat healthy. Engage in decent exercise 30 to 60 minutes a day. Eat healthy means consuming fruits and vegetables on a daily basis. These foods contain anti-oxidants that are believed to retard cancer growth.

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When Mammograms are Wrong: False-Positives and False-Negatives

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First and foremost, let’s get this out of the way: Mammograms are often wrong. In fact, some estimates show that up to 90% of “positive” results (those that have detected abnormalities) are actually “false-positives”, meaning that there was no cancer despite the reading. And up to 20% of “negative” results are estimated to be “false-negatives,” meaning there actually was cancer present but it wasn’t detected.

Any screening test has a chance for false-negatives: it’s impossible to detect anything with 100% accuracy. Getting that percentage of false-negatives as low as possible is one of the reasons procedures are constantly re-evaluated and refined. But I want to focus today on the false-positive tests, because the impact of getting a false-positive on your mammography is a little less understood.

False-Positives

This number – up to 90% – may seem unacceptable at first glance. Getting something wrong 90% of the time is usually considered a deal-breaker elsewhere in life, after all!

According to the National Cancer Institute, false-positives are most common in young women, women who have had previous biopsies on their breasts, those with a family history of breast cancer, and women taken estrogen supplements.

Mammograms can also sometimes detect something known as localized ductal cancer. This is the finding of breast cancer that is localized to the ducts of the breasts known as ductal carcinoma in situ. The concern is that many women with ductal cancers may never die of breast cancer that was diagnosed with the screening mammography. These women may be are subjected to unnecessary breast surgery, radiation therapy and even chemotherapy in older age, leading to health problems and costs that were not truly contributing to their long-term survival.

False-positive tests can result in unnecessary procedures, stress, medical costs, lost time, and additional risks. Believing you have life-threatening breast cancer when you do not can be a tremendously disruptive, life-altering experience in the short term with long-term consequences. So how are you supposed to rely on a mammogram with such accuracy rates?

Using Mammograms the Right Way

It all comes down to how mammograms are utilized. The most important thing to understand is that an initial positive test does not necessarily mean you have cancer. In fact, odds are you do not! But follow-up tests will be needed to learn more information and get to the truth behind the positive result. Additional mammograms, ultrasounds, and surgery followed by biopsy are the typical followups, depending on what is found. It is important not to panic at this stage, and to understand that more information is needed before a complete diagnosis can be made.

Another important factor in using mammograms the right way is understanding when they should be conducted. Young women are much more likely to experience false-positive (and false-negative) results: as a result, for average-risk women the American Cancer Society recommends screening starting at age 45, while the United States Preventive Services Task Force recommends screening start at age 50. Screening in young women has not been shown to conclusively help prevent deaths from breast cancer, and may cause more harm than good in many cases. If you are at higher risk or want to begin screening earlier than these guidelines, you should discuss it with your doctor and understand some of the limitations inherent to mammograms.

As women reach their late years, the benefits of mammograms becomes difficult to determine. Women age 75 and older can still develop breast cancer, but in some cases their remaining life span may be less than the period required for breast cancer to become fatal. For women that are still healthy and likely have a number of years remaining, screening may be a good practice. For others, screening may cause more harm than help. It is recommended that you speak with your doctor and try to determine a plan that is right for you and your health as there are no set, agreed-upon guidelines.

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Mammograms are still the best tool we have

For all their limitations, mammograms are the best tool for detecting early breast cancer and saving lives. Breast cancer is a fatal disease that takes the lives of about 40,000 women a year. If allowed to develop and spread to other parts of the body, it can be too late to save someone with breast cancer. By staying vigilant and following proper guidelines, it is possible to detect this dangerous disease early and save lives. Be sure to speak with your doctor and schedule the right tests at the right times for you!