Here's the background of this disturbing case as I know it. You be the judge.
Janey (not her real name) is a 37 year old female. She came to the United States from the Philippines about 20 years ago. She has three children and about two or three years ago became an American citizen.
Janey felt lumps in both of her breasts a little over two months ago. She went to her primary care physician. She belongs to an HMO (which I will not name), it is one of the largest, not for profit HMOs in the United States.
Her clinican examined her and told Janey to return in two months. Her clinician did not order any further tests. Did not order an immediate mammogram. Janey's instructions were unambiguious--return in two months for a follow-up.
Janey returned last week. The lumps were still there--maybe even a bit larger she says. This time she got a full court press.
She was given nine mammograms and ultrasounds of each breast. I suppose the doctors did not like what they saw and she was told to return three or four days later for biopsies of both breasts.
This is her diagnosis:
Right breast:
Invasive ductal carcinoma
Left breast:
Fibrocystic changes with associated microcalcifcations and benign adenosis
Biopsy, Right Axilla: (I believe this is the medical name for lymph node)
Metastatic adenocarcinoma in a lymph node
I am a cynic. I can't help it, I live in the United States and George Bush is sitting in the White House. There is little that is holy in our country any longer. When I say "holy" I mean, there is little that I trust. I wish I could trust--but I cannot. Perhaps some of you are still able to turn on the trust mechanism--but mine is out-of-order--at least until 2008. So, everything I write here is seen through the eyes of a cynic.
You may be asking why is nyceve adding this rather over the top disclaimer about cynicism? Here's why: all of Janey's doctors have been calling her. Everytime we talk, she tells me about which doctor called to see how she is doing. By the way, she's starting chemotherapy on Monday. She tells me her treatment will consist of three or four rounds of chemotherapy, followed most likely by a mastectomy (possibly a lumpectomy), then more chemo, then possible radiation. Her doctors say her outlook is good.
It's common knowledge within the medical profession that the best way to avoid a malpractice lawsuit to is communicate with your patient. A good doctor-patient relationship does more to protect an errant physician than anything else. There have been numerous studies documenting this.
Maybe Janey's doctors really care. I don't know. I hope they do, she's a beautiful, kind and wonderful person. I hope these doctors treat all their patients with this level of compassion and care. I hope, this is not a big ugly CYA play.
There is troubling research however which shows that non-white women, particularly African-American women, suffer a disproportionate share of delayed diagnosis.
This is from the Amercian Society of Clincial Oncology:
" Results: We identified 49,865 women with breast cancer; 2982 were African American. African-American women experienced the most diagnostic delay, with 20.9% of subjects delayed 1-2 months and 23.5% over 2 months, and the greatest amount of treatment delay, with 29.6% of subjects delayed over one month. Over one-fourth of African-American women experienced three or more months of clinical delay, significantly higher than any other racial group, and a 76% increase over the rate of white women. In mixed-level analyses, African-American race was a strong predictor of delay. After controlling for age, presence of comorbidities, marital status, size of the city of residence, and neighborhood percent under poverty, African-American women had an 89% (95% CI: 1.70-2.10) increased risk of diagnostic delay beyond one month and 58% (95% CI: 1.42-1.76) treatment delay beyond one month. African-Americans had an 81% (95% CI: 1.61-2.04) increased risk of total clinical delay. Conclusions: This study found a strong connection between African-American race and delay. These differences appear to persist irrespective of the degree of illness. Since reviews have found that patients with a delay of three months or more have 12% lower 5-year survival than those without delay, the study's findings have important clinical and policy ramifications."
You can read more here:
http://asco.org/...=
So, I go back to my original question. Is this good medicine? Is this bad luck? Is this just garden variety American medicine?
We really do have many health care systems in the United States, don't we? One for rich, white people with good insurance who can get themselves to the best doctors, at the first sign of a head cold. A second for people with HMO insurance who must languish in the wasteland of managed care and hope the treatment they receive is up to the much heralded high American standards. A third group--the 46 million American citizens with no insurance. These people as we all know, get very sick before they go to emergency rooms for very expensive treatment.
This is American health care circa 2005. We can change this shameful reality if we raise our voices in collective anger.