Modern medicine isn’t addressing women’s distinctive health care needs as optimally as needed, with research further showing it may be time to dial down expectations about breast cancer screening, while heightening physicians’ awareness and best practices in eliminating gender biases.
Women also may want to keep close tabs on how changes with the Affordable Care Act affect them, and they may be well-served to remind themselves about Texas’ sudden surge in maternal deaths and one of health care’s major, gender-based debacles in hormone treatments for females.
Over-treatment tied to mammograms
Let’s start by looking at some distressing Danish research on mammograms, a study published in the Annals of Internal Medicine. The research, based on a decade of data, took advantage of how breast cancer screening spread across Denmark, allowing researchers to compare women who had undergone mammography and those who had not.
In brief, the study found that mammograms detected more small masses that might be cancers. But the emphasis on screening amounted to over-diagnosis and resulted in over-treatment of as many of one in three women. Kaiser Health News summarized the research findings:
The study raises the uncomfortable possibility that some women who believe their lives were saved by mammograms were actually harmed by cancer screenings that led to surgery, radiation and even chemotherapy that they didn’t need, said Dr. Otis Brawley, chief medical officer of the American Cancer Society, who wrote an accompanying editorial but was not involved in the study. Researchers increasingly recognize that not all breast cancers pose the same risk, even if they look the same under a microscope, Brawley said. While some early tumors turn into deadly monsters, others stop growing or even shrink. But assuming that all small breast lesions have the potential to turn deadly is akin to ‘racial profiling,’ Brawley wrote. … ‘By treating all the cancers that we see, we are clearly saving some lives,’ Brawley said in an interview. ‘But we’re also “curing” some women who don’t need to be cured.’
Over at healthnewsreview.org, a health information watchdog site, a blog post notes the particular challenges with over-diagnoses and over-treatment of ductal carcinoma in situ (DCIU), abnormal cells found in women’s milk ducts by mammography and other tests. DCIU is a cause for concern, but it typically is slow growing and does not turn to “invasive and potentially lethal” breast cancer. Although the 60,000 women diagnosed annually with DCIU might be informed that “watchful waiting” would be a sound option for them, too many undergo more aggressive, costly, disfiguring, and painful procedures, instead.
I’ve written how doctors and medical researchers have reconsidered their recommendations on certain cancer screenings, notably the tests for breast (mammography) and prostate (prostate-specific antigen or PSA) cancer. Experts are re-setting their thinking on these most common cancers in women and men, trying to determine which types they detect are fast growing killers that need urgent care versus those that develop slowly and may not require aggressive treatment. Early detection remains a key aspect of cancer care. But it has not proven a panacea with the disease.
Checklists to avert gender bias
Although doctors may consider themselves well-educated and open-minded, when it comes to caring for women versus men, they still may fall prey to implicit bias. Their unintentional reliance on stereotypes or associations not only may harm women, it also can cost them their lives, experts at nearby Johns Hopkins Hospital found. Their trauma experts grew concerned that their women patients were dying due to blood clots and were 50 percent less likely to get care for this preventable problem. They discovered a relatively simple, direct way to reduce systemic gender-bias in their treatment.
Their solution? A rigorous checklist that trauma doctors were required to go through to ensure that no matter the patient’s gender, appropriate steps were taken to avert blood clots. As the New York Times points out, these “gelatinous tangles that can travel through the body and block blood flow [and], kill more people every year than breast cancer, AIDS and car crashes combined. But many of these clots can be avoided — if doctors prescribe the right preventive measures.”
The trauma doctors found gender disparities disappeared when the checklists were strictly followed, providing a template not only for wider use throughout the hospital but in addressing a growing health care concern. As the New York Times points out, the issue isn’t just a worry in corporate boardrooms or in worker pay checks:
In health care, [gender disparities] are especially pernicious. If you are a woman, studies have shown, you are not only less likely to receive blood clot prophylaxis, but you may also receive less intensive treatment for a heart attack. If you are a woman older than 50 who is critically ill, you are at particular risk of failing to receive lifesaving interventions. If you have knee pain, you are less likely to be referred for a knee replacement than a man, and if you have heart failure, it may take longer to get EKGs.
Although some doctors dislike checklists because they find them demeaning and think they rob them of treatment discretion, the mechanism, if thoughtfully constructed and rigorously adhered to, has won a following among those focused on evidence-based approaches in health care, as Dr. Atul Gawande has written in a book and a detailed piece several years ago in the New Yorker. He and other proponents note that checklists can be run through routinely, quickly — and they matter for all patients, especially for women and people of color (who also can encounter race-based disparities in care).
Johns Hopkins now screens all who come into the hospital, 50,000 patients annually, for blood clot issues using the checklists, attaining now zero incidences of preventable cases in medical patients. The New York Times points out that, just at this one hospital, that has meant dozens of women’s lives saved annually.
Obamacare and women’s bad history with health care
Like it or not, the sharp-elbowed politics of the day has pushed publications targeted at women, including magazines like Teen Vogue and Cosmopolitan, to cover timely issues like health care policy. Good for them. The proposals to repeal and replace Obamacare carry special stakes for women.
The partisans aren’t saying if they will carry forward provisions of the Affordable Care Act that benefit women. Bigly. The act barred insurers, for example, from charging women more than men for coverage. Its ban on exclusions based on pre-existing conditions also protected women because insurers can’t refuse them, if they, for example, underwent Caesareans or were treated for sexual assault. Obamacare eliminated rules that prevented women from choosing their own gynecologists, obstetricians, and pediatricians without referral from a primary care doctor.
The ACA also required insurers to include affordable maternity care, which had been excluded in many policies. And Obamacare mandated preventive services for women, including mammograms, Pap smears, and well-baby care without cost sharing. The act told insurers they had to pay for gestational diabetes screening, and breastfeeding supports.
Critics have been infuriated by, and promised to cut off Obamacare mandates for contraception and reproductive services, leading to state initiatives to deal with these prospective challenges. Paul Ryan, the Republican Speaker of the House, also has pledged to defund Planned Parenthood at the time he and others hope to repeal Obamacare. Ryan and his supporters have assailed Planned Parenthood because some of its facilities perform abortions, a procedure they oppose. Supporters point out that federal law prevents the organization from spending taxpayer money on abortions unless the pregnancy threatens the mother’s life or results from rape. They further note that the preponderance of Planned Parenthood’s work is focused on providing preventive health care, birth control, pregnancy tests, and other women’s health care services.
It’s worth noting that Texas— a state whose political leaders have been leaders in the resistance to Obamacare, especially its expansion of health care to the poor through Medicaid, defunding Planned Parenthood, and other ways of slashing family planning aid— is now seeing a doubling of its pregnancy-related deaths. As Pro Publica, the independent investigative online journalism organization has reported: “the Lone Star State [has become] one of the most dangerous places in the developed world to have a baby.”
The site says research on Texas’ woes produced “eye-opening findings” not just about mothers’ deaths “but severe maternity morbidity — complications so serious that mothers might have died without major medical and technological intervention and/or sheer luck. Such cases were far more common than deaths, the report said, and far more common among African-American women.”
Expert analysis also shows that:
The leading cause of maternal deaths wasn’t one of the traditional culprits (hemorrhage, infection, pregnancy-induced hypertension) but rather cardiac problems. The second leading cause: drug overdoses. Hemorrhages and blood transfusions were the biggest factors associated with severe complications. And women aren’t just dying in the hospital during or immediately after childbirth. According to the new report, about 60 percent of maternal deaths occurred six weeks or more after delivery. That figure is particularly important because more than half of the nearly 400,000 births in Texas every year are covered by Medicaid, but benefits for many mothers expire 60 days after they give birth. The lack of health insurance — Texas has the largest number of uninsured people in the country and has rejected Medicaid expansion under the Affordable Care Act — could be contributing to maternal deaths and near-deaths.
If current events don’t raise women’s concerns sufficiently about their health care, they may want to take the deep dive into story on the harms of the first-ever synthetic estrogen, diethylstilbestrol, or DES. It was promoted first in the 1940s, especially by male researchers and physicians, as a way for women to smooth out their lives and diminish fluctuations tied to their hormones and monthly cycle. Tens of millions of women took the drug, many during pregnancy, because it also was thought to help prevent miscarriages.
Instead, as the story reports, research first published in the late 1970s tied DES to a rare type of vaginal and cervical cancer in the offspring of women who took the drug during pregnancy. Sons and daughters of women who took the drug have suffered a range of complications, with increased cancers, infertility, and abnormalities of their reproductive systems.
I’ve seen in my practice the great harms that can result from dangerous drugs, and I’ve come to appreciate the huge role and burdens that women bear, not only heading households but also serving as the real decision-makers about health care in families. Gender disparities must be addressed, and we need to ensure that women and men aren’t subject to harmful overtreatment. I’ve also seen the huge pain and suffering that can occur for babies and children due to poor and negligent medical care, and, as a society, if we can’t with sound public policies and investments launch youngsters well and healthy into full lives, well, shame on us. We must do better.
