In Practice: A system’s slowness can be a breast cancer patient’s enemy
It’s Tuesday afternoon, and I’m late for the office, delayed by a hectic morning in the operating room.
I discard my scrubs, replace them with office attire, rush down a corridor and deliver the post-op orders from my last case into the hands of an anxiously awaiting recovery room nurse. Then I dart out the door and race to my office building.
I open the waiting room door to a standing-room-only crowd that has accumulated due to my tardiness. I apologize, but they do not seem angry; I see only fear.
I enter my office and look at the first patient’s chart.
Mrs. M is a 42-year-old female referred for surgical evaluation of an 8-centimeter left-breast mass. I review the mammogram and ultrasound report, and notice that they were performed nearly four months ago. The reports clearly document that the mass was highly suspicious for cancer and recommend a biopsy. I search the chart, but I can find no biopsy report.
She is a kind-appearing woman, with her 13-year-old daughter and husband by her side. I sense their anxiety and attempt to find words that will comfort but not mislead them. I ask when she first noticed the mass. She says it was late December or early January. I ask why she did not seek medical attention earlier, and she says that she tried. As she struggles to explain, she starts to cry.
I hand her a tissue and probe no further. When she has stopped crying, I ask if I can examine her. She opens her gown and reveals a visually obvious breast cancer.
Sadly, cases like that of Mrs. M are all too common. That very same day, I see another one. Such late presentations are very disheartening for physicians and nurses who treat breast cancer.
Our understanding of breast cancer today surpasses that of all other common cancers. The vast majority of women diagnosed in 2011 will survive due to advances in radiology, surgery, medical oncology and radiation oncology.
The lifesaving benefits of screening mammography, breast ultrasound and breast MRI have resulted in an at least 25% reduction in breast cancer mortality.
Refinements in surgical techniques now spare women from the disfiguring and even disabling surgery that removed the breast and chest wall muscles.
Advances in chemotherapy and the development of biologic agents such as tamoxifen, Arimidex and Herceptin have greatly increased survival rates, and the sophistication of our drugs stands to only increase as scientists learn more about the genetic pathways involved in progression of the malignant process and the development of drug resistance.
But in Los Angeles’ San Fernando Valley and the country’s many other underserved areas, women with breast cancer often are treated too late to benefit from these advances. The preventable deaths that result are a tragedy.
Many factors contribute to the failure, but the main one is lack of timely access to diagnosis and treatment services.
Generally, a patient is covered either by Medi-Cal (California’s version of Medicaid) or an HMO. A potential problem is identified through mammography or, in some cases, after the patient feels a lump. The patient seeks medical help.
If she has Medi-Cal, she is entered into the county health system. In 1998, as a young surgical oncologist, I worked within this system at Los Angeles County-USC Medical Center. The staff worked tirelessly but was overwhelmed by the volume of patients and limited resources. There are excessively long wait times for the initial consultation and subsequent biopsy. Surgery can be delayed for months.
Similarly, those insured with some HMOs often encounter delays caused by long waits for appointments with primary-care physicians who function as gatekeepers and further waits for referrals to specialists and procedures.
When patients are not insured, California’s Every Woman Counts cancer detection program — offering women 40 and older a mammogram and, if needed, a biopsy — offers a safety net. If cancer is found, the patient is eligible for Medi-Cal.
This program has been a lifesaver for many, but for several months over the last year it was suspended because of budgetary constraints. The program does not adequately reimburse providers, so participating centers have difficulty covering the cost. And since women younger than 40 are ineligible, they have no safety net should they feel a breast mass.
We frequently see new patients who had become aware of a potential problem four to six months earlier. We expedite treatment, but by then they often have advanced disease and are not candidates for breast conservation. Many are relatively young and have missed the window of opportunity for cure.
The failure of our medical system to ensure that all women realize the benefits of advances in breast cancer prevention and treatment is bewildering. Each year, millions of dollars are allocated for breast cancer research. Meanwhile, the system does not provide the resources to fully employ tools we already have, resulting in a tragic and needless loss of life.
When we see patients leave the lives of the spouses and children who love and need them, I often am reminded of the words of the 19th century poet John Greenleaf Whittier: “For of all sad words of tongue and pen, the saddest are these, it might have been.”
Lomis is chairman of the department of surgery at Valley Presbyterian Hospital and director of the Valley Breast Care and Women’s Health Center. Reach him at thomaslomis@sbcglobal.net.
