Archive for the ‘Cancer’ category

None Dare Call It Murder

February 1, 2012

I’ve got just one quick note to add to the discussion of the Komen Foundation’s surrender to Greater Wingnuttia and the Global War on Women.

That would be that this decision is not just about the dollars.  It’s genuinely a matter of life and death  — of murder, really, with only the anonymity of the victims to obscure the the connection between act and consequence.*

Y’all may recall that I wrote along these lines about eight months ago in connection with Mitch Daniels’ decision to defund Planned Parenthood in Indiana.  (Yup, that Daniels — the hack our friends in literate Wingnutistan see as the great hope of the GOP).  Now we’re back again to run the numbers on what the removal of the services Planned Parenthood provides to women seeking preventative care for breast cancer will do.**

Here are the basic figures:  over the last five years, the Komen Foundation provided Planned Parenthood with sufficient support to pay for 170,000 breast exams and 6,700 referrals for mammography. The question of how frequent and how early a mammography program should be has been, shall we say, vigorously debated, but the issue gained some clarity last year with the publication of a large scale longitudinal study by Swedish researcher in which over 133,000 women were followed for a total of 29 years.

The results of this study provide low-end estimates for the lives saved by screening:  for every 414 or 519 women screened*** for seven years running, one breast cancer death would be prevented.  What’s more, the researchers emphasized that this is a conservative conclusion:

Evaluation of the full impact of screening, in particular estimates of absolute benefit and number needed to screen, requires follow-up times exceeding 20 years because the observed number of breast cancer deaths prevented increases with increasing time of follow-up.

I’m being deliberately dry in this telling, and I’m sure you can guess why:  I do not wish the conclusion to lose any of its force to misplaced snark.  The bald facts are grim enough.

How grim?  Take the most modest number from this study —519 women screened for each life saved.  That’s on the order of 13 women from the 6,700 screened with Komen Foundation money who get to live.****

Or:  that’s 13 women who will die for lack of those funds.

As I wrote about cervical cancer screening in Indiana:  we won’t know who those women are.  We will never know their names; who loved them; how many kids they will leave behind.  But if the total funds for screening in the system drop with the withdrawal of Komen Foundation support, they’ll be dead all the same.

Caveats, before I drop this “just the facts, Ma’am” tone:  this is a blunt, back of the envelope bit of arithmetic.  There are all kinds of factors that a real epidemiologist would consider before making any such bold claim.  Some of the obvious ones push the conclusion to a higher likely total of preventable deaths:  these women are being referred for screening, which suggests that someone had an inkling that they might be at risk.  Planned Parenthood sees a clientele that is likely to lack more health care services than the general population.  And there are the general points the original researchers made to suggest that the total of lives saved through screening would be greater than their baseline number.  There are probably factors that weigh in the other direction as well — one could imagine, for example, that the preliminary examinations turned up more aggressive cancers, which may have outcomes that mammographic detection does not much alter.  You get the point.  The reality of public health, medicine, and the basic biology of cancer is such that precise predictions are always wrong.

That said, the broader claim still stands:  there is a significant and growing body of evidence that regular mammographic breast cancer screening saves lives.  The converse follows:  withholding that screening means real people will suffer.

And here I’ll drop the pretense of dispassion.  The Komen Foundation’s decision links directly to illness, to death and loss and dreadful sorrow left behind.

Those losses can’t be called manslaughter either, not as I see it.  Preventable deaths that flow from lack of access to the standard of care are wholly predictable, even if the individual victims are not identifiable.  Those blocking access through want of funds know — or should — what will happen.  There’s nothing accidental about these outcomes.w

Which means that this isn’t just another salvo in the culture war.  This is nothing to be clever about in 850 word columns on the back pages of the Grey Lady.  This is not a bit of clever gamesmanship to rev up a base for whom just the name Planned Parenthood conjures up all their horrors of female agency.

This is real life, and real lives lost…and, once again, this is why this election matters so much.

*Yup.  Still working the refs for that Moore Award.

**Just to be clear:  for what follows, I’m assuming that these services are withdrawn, that the withholding of resources from the Komen Foundation doesn’t get made up somewhere else.

*** The spread is down to the details of data collection and analysis in the Swedish study.

****The weasel is about the difference in the five year span of screening Komen funds are said to cover, and the seven year screening sequence identified in the Swedish study.  I lack both the data and the skill to do more than waffle a bit here.

Image:  Artemisia Gentileschi, Jael and Sisera, 1620

“The First Thing A Principle Does Is Kill Somebody”

May 1, 2011

Thus sayeth Lord Peter Wimsey in Dorothy Sayers’ Gaudy Night — and while it offers unmerited dignity to Gov. Mitch Daniels to accuse him of possessing a principled moral judgment, it is still true that his decision to defund Planned Parenthood will kill some number of Indianans.

Given that he has foreknowledge (or should, by any reasonable standard) of this outcome; given that he is doing this intentionally — after all, he has committed himself to the affirmative action of signing the bill in question; given that the consequences of this choice are readily recognizable to any mature observer, I know how I would characterize this act. YMMV. The blunt fact remains that mortal harm is coming to some women in his state as a direct result of his actions.

What’s this all about?  Well, Kay here already noted the key fact:  Planned Parenthood in Indiana is a major supplier of healthcare to women in poverty; withdrawal of that care we lead directly to premature deaths.  That fact is implicit in what Kay wrote.  All I want to do here is to make it explicit, to leave no ambiguity in the demonstration that the approach to health care policy taken by Daniels — and Republicans in general — leads directly to the deaths of Americans.

__

From whence derive these –dare we call them murders?  Take a look at one of the most basic services Planned Parenthood provides its clients:  regular maternal and reproductive health care, including screening for one of the most preventable major diseases that afflict women, cervical cancer.  I’m going to do a bit of boring data dumping here, because I want to make the indictment of Daniels — and those who follow or admire him — as clear as possible

According to the CDC, about 12,000 women in the US were diagnosed with cervical cancer in 2007, the latest year for which I can find summary statistics. About 4,000 women died that year of the disease.  Many or most of those deaths were, or would soon be unnecessary, evidence of failures of public health, given that cervical cancer is preventable at very high rates.

For one route  vaccines exist that protects against infections by two of the most dangerous human papillomavirus strains implicated in the development of cervical cancers, and they are recommended by the CDC for girls and young women as early as possible (as young as 9) to protect against such viruses before risks of exposure mount.

Right wing opposition that to my jaundiced eye looks to oppose anything that might hint at independent sex lives for women has hindered the widespread application of one of the lowest cost, least invasive life saving medical interventions we now possess, one that could, as the raw numbers above suggest, save many thousands from the suffering involved in cancer treatment — and thousands again from dying unnecessarily from a wholly preventible disease.

The other path to prevention is, of course, the use of a screening test, the Pap smear, to catch the lesions that can proceed to full blown disease before they become malignant.

The US Preventative Services Task  Force (among many others) recommends that women begin a regular screening regimen within three years of the onset of sexual activity or their twenty first birthday, whichever comes first, to be repeated every three years until the age of 65, barring the presence of certain risk factors for the disease.

Such screening saves lives.  Lots of them.  Many sources report that a regular screening program with appropriate follow up reduces cancer incidence rates by up to 80%.  In the US that has corresponded to a drop in new cases from 14.2 per 100,000 in 1973 to rates about half that now, leading to 3 deaths per 100,000.  In Indiana itself, 2.4 white women per 100,000 were diagnosed with the disease in 20007; the number for African American women was 5.7 per 100,000.  That disparity may be due more to poor health services infrastructure and follow up for minority communities than to lack of access to screening itself; just about every source reminds the reader that the screening on its own can do nothing, unless action on the information thus gathered can occur.

All of this is background to this one datum: Planned Parenthood in Indiana delivers 500 Pap tests per week, and provides crucial health care support and services that allows the women it serves to do something about problems when detected.

Y’all know where this is going.  Pull 25,000 tests per year out of state health care system; do so for a population that is almost certain to include the most vulnerable and the least secure in their access to ongoing care, and you have a hot spot of cervical cancer cases waiting to happen.  If rates among that group revert to those comparable to countries with poor screening regimes – Romania in the late ‘90s, for example, with its Europe-high rate of 13.7 deaths per 100,000 – the back of my envelope tells three or four more women every year will die in Indiana unnecessarily – all for lack of access to the Planned Parenthood services that could have saved them.

I’ve been deliberately dull above, after my high-rev open.  The point I’m trying to make with this list of data and other people’s work is that there is not a political bone (or fibril) in the human papilloma virus.  HPV don’t care if you vote Republican or Democrat or The Rent Is Too Damn High.  It doesn’t judge you whether you have sex with one person….

…or if you like to do it like they do on the Discovery Channel.  It could give a viral sh*t what you think of the PDF of Obama’s birth certificate.  It shows up, gets nice and comfortable.  And then some women get sick, and some die.

And can I say again that those deaths are in principle wholly preventable?

Planned Parenthood does lots more than screen for gynecological cancers, of course.  This is just one example of the real commitment to saving lives, to life, that marks that organization.  But this story makes the point well enough:  when you cut poor and vulnerable people’s access to health care real harm results.

Which means that Mitch Daniels is presenting his bonafides to the Republican electorate with an action that will lead directly to the deaths of women whom he doesn’t know – whom he and we cannot know.  That anonymity, the statistical nature of the crime, means that Daniels will almost certainly never pay any price, let alone a criminal one, for his role in their deaths.  But they will be on his hands, and should be on his conscience.

And to go larger than just one politician whose ambition has swamped his capacity for moral reasoning, this is why we must work for more than just an individual electoral defeat for today’s Republican party.  Mitch Daniels may indeed by the best they’ve got over there.  That’s as damning an indictment as I can imagine.

Factio Grandaeva Delenda Est.

Images:  Egon Schiele, Death and the Woman, 1915.

Albrecht Dürer, The Flight to Egypt, 1494-1497.

Breast cancer news, a lesson on genes and environment.

January 10, 2008

A day late, but I wanted to link to this post in Tara Parker-Pope’s Well Blog on nytimes.com. First — the study Tara highlights is important, adding nuance (and difficulty) for women who discover they have certain mutations tied to very high probabilities of getting breast (and ovarian) cancer who try to interpret that knowledge.

As Tara writes, mutations in genes BRCA1 and BRCA2 had been viewed as almost certain indicators of cancers to come. Now, a report by a team at the Memorial Sloan Kettering found that the risks seem both to be somewhat lower than previously thought, and — this is the crucial bit — to vary significantly depending on other factors in different subgroups of patients.

The low end of the scale they observed was around a 36% chance of getting cancer by age 70 — still bad, from where I sit — but clearly a significantly different risk profile than the almost pure genetic determinism of the bad gene = cancer view.

(By the way, this is exactly the stuff that Masha Gessen deals with eloquently and in depth in her forthcoming book, Blood Matters, which I highly recommend when it goes on sale in April.)

Beyond the news itself, there is an important idea lurking in the background:  in their report, the authors suggest that other, still-unknown genetic differences, underlie the differences in outcomes for the women they observed in their study.

That is: the genomic environment of surrounding the known cancer-implicated genes is what they believe shapes whether and when BRCA1 and 2 mutations lead to disease in a given patient

John Maynard Smith, one of the less publicly celebrated great biologists of the 20th century, emphasized the importance of this kind of finding  when I had the good fortune to interview him a few years ago.  He demanded that I understand that the environment for a gene begins with the chromosome on which it finds itself, and then broadens out to include the rest of the genome in which it lies, and then on out from there. What happens in the molecular environment of the gene is crucial, both in regulating the normal interaction between different genes and non-coding bits of DNA, or when some variation or derangement of normal function affects the action of any given gene.

That subtlety gets lost, often, when genetics hits the public square.  See, for example, Lucky Jim Watson genes-and-IQ skirmishes of late last year.  It’s easy for both researcher and reporter to fall into a kind of naive genetic determinism. One looks for the gene for some trait or disease; one reports that the gene for a given problem has been found — and then later, sometimes years later, it becomes clear that whatever is going cannot be that simple.

John Maynard Smith was very elderly when I met him, and had seen a lot, the entire modern history of genetics, from the double helix on. He knew better. It’s an important lesson to remember.

Image: Charles Alston, “Modern Medicine.” Location: Harlem Hospital. The work was commissioned by the US Government and is hence public domain. Source: Wikipedia Commons.