Screenings, recommendations, motivation help us to live longer
PRESQUE ISLE, Maine — As people live longer and medicine gets more complex, it’s important to be an advocate for your own health, suggests Lucy Richard, a nurse practitioner with The Aroostook Medical Center.
Today, people have more health information available than ever before, but also pharmaceutical advertising and public health recommendations about everything from diet to cancer screenings.
At the County Women’s Health Conference hosted by TAMC, Richard sought to offer a window into the continued evolution of women’s health care and get women, as well as men, thinking inquisitively.
“It’s really important for a patient to ask questions,” Richard said. “Ask about statistics. What is my risk factor? What would be my risk of getting cancer? We’re already doing that with cardiovascular health. If we gave people those statistics, they’d be better informed about making those decisions.”
Under the Affordable Care Act, “if you have insurance, you can get preventive care, prenatal care, mammograms and pap smears at no deductible, copay or other cost to the patient,” Richard said, referring to the health law’s requirements for coverage of preventive care.
When it comes to the navigating those choices,“I want my patients to be making part of the decisions for themselves,” Richard said. Patients are being asked to make more shared-decision making in part because medicine is getting more complex and nuanced, as in the case of mammograms, the X-ray technology used in detection of breast cancer.
Since the early 1990s, women were urged by the American Cancer Society to receive annual mammograms starting at age 40, based on the idea that “early detection saves lives.”
In 2009, that longtime advice was turned on its head by U.S. Preventive Services Task Force, an independent health panel whose recommendations can determine insurance coverage. The PSTF recommended that women between ages 50 and 74 receive mammograms every two years, and that those under 50 should consider it on an individual basis based on a number of pros and cons.
The PSTF reviewed the evidence again last year and finalized its 2009 recommendation. “The decision to start screening mammography in women prior to age 50 years should be an individual one,” the task force wrote in its summary. “Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.”
The PSTF graded biennial mammography in women ages 50-74 with a B-rating, a service defined as a “moderate to substantial” net benefit. Services with A- or B-ratings also mean health insurers must cover the full cost.
The task force gave mammograms for women under 50 a C-rating, which comes with a recommendation for “selectively offering or providing this service to individual patients” and no mandate for full insurance coverage.
“While screening mammography in women aged 40 to 49 years may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger,” the PSTF wrote. “In addition to false-positive results and unnecessary biopsies, all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to their health, or even apparent, during their lifetime. Beginning mammography screening at a younger age and screening more frequently may increase the risk for overdiagnosis and subsequent overtreatment.”
Last fall, before the task force finalized its guidelines, the American Cancer Society raised it recommended age for starting annual mammograms to age 45 and suggested that biennial screenings starting age 55. The American College of Radiology, a medical association representing many physicians performing imaging tests, continues to recommend that women get yearly mammograms starting at age 40.
Richard, who’s been working in health care for three decades, said there are areas of uncertainty in many aspects of medicine, especially with recommendations for testing. “I think a lot of the hospitals and health care providers are being encouraged to follow the guidelines, but health care isn’t one-size fits all.”
For long-term smokers and former smokers ages 55 to 80, the PSTF has given a B-rating to annual screening for lung cancer with low radiation computed tomography scans, based on a large study finding that 30-year pack-a-day smokers had a 15 to 20 percent lower risk of dying from lung cancer than participants who received standard chest X-rays, with the cancer being more treatable in its earliest stages.
Ovarian cancer, meanwhile, does not have a good screening, and can really only be tested for via a biopsy. It’s one of the diseases that technology still needs to catch up to — and non-invasive testing technology in general could still benefit from advances, Richard said.
“Think how far your computer and cell-phone has come in the last 10 years. We haven’t done anything in new technology to have something could really detect breast cancer better so that people wouldn’t have to have some kind of screening,” she said, noting that mammograms are also thought to miss about 15 percent of concerns.
Some areas of health care are backed by good evidence, and there are small changes that can address the intertwined problems of diabetes, obesity and heart disease.
Richard says she wants her patients to make “smart” goals — actions for their health that are specific, measureable, attainable, realistic and timely. Richard’s herself is aiming to walk about 10 percent more every week.
“When you go to the doctor or clinic, try to come away with something that motivates you to want to want to pursue walking goals or avoid getting a diagnosis of diabetes or hypertension,” Richard said.
Hypertension, aka high blood pressure, “is really an issue. Maybe it’s our diet, maybe it’s our inactivity, maybe it’s our stress levels,” Richard said. Unlike drugs for other chronic conditions, though, there are blood pressure medicines that work well and have little or no side effects.
It’s also good to get cholesterol levels checked to find out the overall number and the relation of HDL and LDL. Less than ideal cholesterol test results do not necessarily mean people should start taking statins, Richard said. “It might mean you really have to pay attention to lifestyle changes — what you’re eating, how much you’re exercising and what you’re weight is.”
And diabetes, which in combination with poor cholesterol, high blood pressure and excess weight significantly raises a person’s risk of cardiovascular disease, can be tested for affordably and help provide an impetus for change. With blood sugar tests for diabetes, Richard says, “if you’re borderline, sometimes just making those lifestyle changes can keep that at bay for years.
TAMC and other large medical providers are also working to address those kinds of chronic conditions through both the traditional medical settings and through outreach and community-based programs, said Joy Barresi Saucier, TAMC’s chief strategy and community benefit officer.
TAMC recently completed its community health needs assessment and will be focusing on four topics over the next year — decreasing youth obesity through family engagement, decreasing cardiovascular risk factors in our working age adults, helping seniors manage chronic conditions, advocating for improved mental health services.
In a survey, 20 percent of Aroostook County adults rated their health as “fair to poor,” Barresi Saucier said. More than 40 percent of Aroostook County adults report having high blood pressure, more than a third are obese and 27 percent have a sedentary lifestyle.
“This is where we’re at, and in order to address the challenges we have to come together,” said Barresi Saucier, who is also a registered nurse. “We have to take individual accountability not only for ourselves but those in the community.
