Colorectal Cancer Screening: 80% by 2018

Katie Couric has raised awareness of colorectal cancer ever since her husband died of the disease in 1998. Yet colorectal cancer remains the second leading cause of cancer death in the United States, only surpassed by lung cancer. Both are preventable: lung cancer by not smoking, and colorectal cancer by screening for and removing precancerous polyps.

The American Cancer Society has teamed up with the CDC (the Centers for Disease Control and Prevention) and other organizations to set an ambitious goal of screening 80% of eligible people for colorectal cancer by the year 2018. Screening for colorectal cancer is incredibly important because removing precancerous polyps actually prevents colorectal cancer. Across the nation, if 80% of the eligible population gets screened, it would prevent 277,000 new cases of colorectal cancer and 203,000 deaths (270 of those in Angelina County!) within 20 years. Those are staggering numbers.

Why so high? Because one in three adults in the United States between ages 50 and 75 – about 23 million people – are not getting tested as recommended. In Texas in 2016, there will be 9,680 new cases of colorectal cancer and 3,520 deaths. This translates in Angelina County to about 36 new cases and 14 deaths this year alone. Remember, these are preventable deaths.

How are we going to achieve this screening goal locally?

The Angelina County & Cities Health District, CHI St. Luke’s Health Memorial, the Temple Cancer Center and our local gastroenterologists have teamed up with the American Cancer Society and CPRIT – the state-funded Cancer Prevention Research Institute of Texas – to educate our area population and screen eligible patients for colorectal cancer through a cooperative grant headed by UT Tyler. Most insurances cover routine screening, but this group stands ready to make sure that any eligible patient, whether insured or not, has access to life-saving screening and, if a cancer is found, treatment as well.

There are many ways to be screened, but I want to focus on the two most available. These two  - colonoscopy and FIT testing – are also funded under the CPRIT grant and by almost all insurances. Having a colonoscopy is the best test, in my opinion, because if any polyps are found they can be removed right then and there. If the colonoscopy is negative, nothing else needs to be done for 10 years! My wife and I had ours done the year we turned 50, and it really is not a big deal. Yes, you have to do a bowel prep to clean out your colon, but that is a small price to pay for peace of mind for 10 years.

The second test covered under the CPRIT grant – and the one that will be done most often at the Health District – is the FIT (fecal immunochemical) test. It is a test for hidden blood in the stool, which can be an early sign of colon cancer. This test is done at home by using a small brush to collect some stool and place it on a test card. The test kit is then mailed back to the clinic for processing. The FIT test must be done every year, as opposed to the colonoscopy every 10 years, but it is cheaper and doesn’t require a bowel prep. If the FIT test is positive, a colonoscopy is then necessary.

If you are between the ages of 50 and 75 and have not had a colonoscopy in the last 10 years or had an annual FIT test, ask your doctor to schedule you for one. If you do not have insurance, call Angelina County Connects at (936) 633-1442 and ask the eligibility specialists if you qualify to be screened under the CPRIT grant. Let’s work together to prevent cancer and get to 80% by 2018!

The Significance of an Ethical Foundation

Last month, I wrote about the role of the hospital Ethics Committee and commented that open and honest communication between healthcare professionals, patients and family solves most ethical dilemmas. That assumes we are speaking the same ethical language and have a common ethical foundation, both in medicine and in society at large. In our increasingly pluralistic society, that is no longer a safe assumption. The recent Orlando attack on a gay nightclub showed us that people can do terrible things when ostensibly motivated by a perverse ethic or belief system.

Ethics, at its core, is simply a set of moral principles or values which guide an individual’s – or a religion’s or a government’s – actions. In the United States, that governing set of principles has been rooted, sometimes more and, regretfully, sometimes less, in a Judeo-Christian ethic based on the inherent (and, according to the Declaration of Independence, Creator-endowed) equal value of every individual. In medical ethics, the two related guiding principles date much further back, to Hippocrates around 400 BC: the sanctity of human life and the concept of “first do no harm”.

Modern medical ethics rests on four major pillars: Autonomy (the patient decides), Beneficence (does it help), Non-maleficence (don’t harm), and Justice (is it fair or impartial). In other words, do our medical recommendations and interventions respect the rights of the individual patient, are they helpful, do they not do harm, and are they fairly and equally available. It is a tall order to keep these broad principles in mind, especially when trying to balance competing interests with limited resources.

American history in general – and medicine in particular – has tended to elevate Autonomy over and above her sister principles. We are a pioneering, individualistic “I did it my way” society. The winds appear to be changing, both in healthcare (with the move toward universal healthcare) and in political discourse. The traditional emphasis on the individual’s responsibility in his or her own pursuit of happiness is taking a back seat to the notion that it is the government’s role somehow to guarantee equal outcomes, seemingly regardless of effort, for all. For example, we just completed a groundbreaking primary season where an avowed socialist garnered significant support on a platform of income redistribution.

Amidst this sea change of process, of roles and responsibilities, can we agree on a common ethic to guide us?

I firmly believe that regardless of who we elect and within whatever system of healthcare delivery we end up with, a Judeo-Christian emphasis on the inherent, God-given value of each and every individual (whether black or white, gay or straight, handicapped or not, born or unborn) is uniquely protective of both the individual and society as a whole. Mass shootings and terrorist acts demonstrate that our moral ethic (or lack thereof) determines our behavior. To paraphrase a Dostoevsky character in The Brothers Karamazov: If God does not exist, all things are permissible. A disturbing corollary appears to be: If my moral ethic condones and encourages killing lots of people, why not do it?

Motivational speaker Zig Ziglar once said, “Since belief determines behavior, doesn't it make sense that we should be teaching ethical, moral values in every home and in every school in America?” Whose values? All belief systems are not equal. Governments and terrorist organizations which do not value the individual, inherent worth and equality of “all Men” – to again reference the Declaration of Independence – are not going to treat their (or our!) citizens equally. In fact, they may kill them (and us).

If I had to choose one word to describe the ethical principle I pursue in life and in healthcare, it is love. Not hate, not selfishness. Not religious dogmatism. And not a “love” of government, cult or fanaticism that discriminates or (God forbid!) kills others in the name of some god or political whim. It is the pure Christian commandment to “Love your neighbor as yourself.”

Is this idealistic? Absolutely. Is it achievable? No, to be honest. But that doesn’t mean I stop working tirelessly, incessantly toward that goal. Our country should do the same.

The Role of the Hospital Ethics Committee

For most of my 25 years in medical practice, I have been involved in hospital ethics committees. You may not know that ethics committees exist, or that there are ethics consults in hospitals.

An ethics committee is a group of people ranging from physicians to chaplains, nurses, social workers, and sometimes community representatives who may meet to develop policies on topics like end-of-life care or medical decision making. It is easy to understand that conflict may arise, for example, when a patient is unable to voice their desires and family members don’t agree; it is much harder to devise or articulate a process toward a solution. Sometimes state or federal law dictates a path; more often, a Solomon is needed to split the proverbial baby. Hence, the Ethics Committee can be consulted to advise on a course of action.

In each institution I have been associated with, the Ethics Committee does not decide which course of action to take. They merely facilitate discussion between parties, advising on known statutes or regulations, and – more than anything – making sure each party is hearing what the other is saying. Most ethics consults end up being non-issues; once communication is clear between parties, agreement on a course of action is often reached.

On rare occasions, family members insist on care being provided or continued when, from a medical standpoint, that care is considered futile (or, in PC-speak, non-beneficial). This is a perfect example of #firstworldproblems. It was only in the 1960s that coronary care units came into existence. Prior to that, death in the home was the norm, with family at the bedside. With the advent of intensive care, we have come to expect immortality in the Temple of Medicine.

As reported in 2010 by PBS’s Frontline program Facing Death, nearly half of all Americans die in a hospital (nearly 70% in a hospital, nursing home or long-term-care facility), while 7 out of 10 Americans say they would prefer to die at home. More than 80 percent of patients with chronic diseases say they want to avoid hospitalization and intensive care when they are dying. Yet only 25% actually die at home. The difference between desire and actual care is striking.

Why, if we want a certain type of care, do we not get it? For one, we don’t effectively make our wishes known. In that same Frontline series, only 20 to 30 percent of Americans report having an advance directive such as a living will. And, even when patients have an advance directive, physicians are often unaware of their patients' preferences.

The default action in hospitals is to provide any and all care possible. Blame our perverse incentive to do procedures, our desire to avoid litigation, and our misguided belief that we can save everyone, and you get patients dying in the hospital not even knowing they are at the end of life. It is this window where a hospital Ethics Committee is most consulted.

In my personal experience, the ethical conflicts that arise within a religious context are the most frustrating. Some patients or families hold on to the miracle cure lottery ticket, demanding care that is both ineffective and injurious, afraid to let go of “faith”, as if death itself is under their control.

That type of faith – sincere as it may be – is nothing more than magical thinking that binds God to the believer, making God not even a god, but a puppet. As Billy Graham reportedly said, “Prayer is the rope that pulls God and man together. But, it doesn't pull God down to us. It pulls us up to Him.”

In healthcare, there is no “right” to expect or demand care that is not appropriate. Physicians have an obligation to “first, do no harm”. This is nowhere more important than at the end of life, where comfort care and quality of life are paramount. To bridge this unnecessary divide, open and honest communication between healthcare professionals, patients and family is key. When communication breaks down, the Ethics Committee can help.

Lung Cancer Screening Saves Lives

For more than 50 years now, we have known the dangers of smoking. That smoking causes heart disease, emphysema, and lung and other cancers is not in dispute. For fifty years, we did not have an effective screening tool for lung cancer.

Now we do.

Medical imaging has improved so much that we are now able to do computerized tomography (CT) scans with significantly lower dose to the patient and at a low enough cost to warrant widespread use as a screening tool. Not everyone needs a scan, of course. But smokers who are at high risk of developing lung cancer now have an option for screening, much like mammography for early detection of breast cancer.

In 2011, the results of the National Lung Screening Trial (NLST) were published in the New England Journal of Medicine, arguably the foremost medical journal in the world. This trial screened current or former heavy smokers aged 55 to 74 with low-dose CT scanning of the chest and compared it to standard chest x-ray. The NLST primary trial results show 20 percent fewer lung cancer deaths among trial participants screened with CT compared to those who got screened with chest x-rays. This is huge news, because we haven’t cured a lot of lung cancer over the last 50 years! Based on these results, the Centers for Medicare & Medicaid Services (CMS) decided in 2015 to start paying for the procedure on January 1, 2016.

According to the American Cancer Society, in 2016 an estimated 224,390 people in the U.S. (117,920 men and 106,470 women) will be diagnosed with, and 158,080 men and women will die of, cancer of the lung and bronchus, the leading single cancer killer in the U.S. If everyone who was eligible got screened, more than 30,000 deaths from lung cancer could be averted every year.

There are more than 94 million current and former smokers in the U.S. at high risk for lung cancer. In 2014, an estimated 18.1 percent, or 40 million U.S. adults, were current cigarette smokers. Unfortunately, smoking rates in East Texas are higher than state and national averages. That means a lot of East Texans are eligible to be screened.

Starting last fall, CHI St. Luke’s Health Memorial began offering low-dose CT lung cancer screening to eligible patients. Medicare covers ages 55-77 (commercial insurance 55-80, but Aetna 55-79). Even within those age ranges, an eligible patient must be a current smoker (or quit no more than 15 years) with at least a 30 pack-year history of smoking (for example, smoking 1 pack per day for 30 years, or 2 packs per day for 15 years). And, eligible patients must have no symptoms of lung cancer (such as coughing up blood or unexplained weight loss of more than 15 pounds in the last year). If lung cancer is suspected, a standard CT chest should be done.

Finally,  Medicare requires “shared decision making” on the risks and benefits of lung cancer screening, which means you must meet face to face with your primary care provider to get an order for screening.

Since we started screening at CHI St. Luke’s Health Memorial, more than 70 patients have been screened. Six abnormalities have been found (including an incidental kidney mass), and two lung cancers have been diagnosed. Those two cancer patients’ lives may have been saved by screening; only time will tell.

Of course, the best way to prevent lung cancer is by not smoking. Ever. Quit if you do smoke. And if you meet the criteria listed above, talk to your doctor about getting screened for lung cancer. If you have questions, feel free to contact the Temple Cancer Center at (936) 639-7466 for more information.

Let's Not Get Trumped

I am ashamed. I wrote that phrase recently on a Facebook post of two Finnish friends who are looking across the ocean with a combination of disgust and disbelief at the Trump phenomenon. Consider my vow to avoid public political commentary this year broken.

The first president I ever voted for was Ronald Reagan in 1980. I have voted Republican ever since. But I will not vote for Trump if he is the Republican nominee. Don’t worry… I’m not voting Bernie Sanders, either. The socialist movement in the Democratic Party is just as disaffected and radical as the Trump wing of the Republican Party… and just as dangerous to our American way of life. We are not Finland. But with Sanders, you know what you get. With Trump, all bets are off.

Trump's campaign speeches are bullying and belittling, full of empty rhetoric and supportive of (indeed, encouraging) violence. I don't care how angry you are at the “establishment”; there is no place in American politics for Trump’s inflammatory, derogatory speech. Yes, he has a right to say those things. But shame on each and every American who jumps into the pig sty with him, eggs him on, and actually votes for him! Regrettably, all of us on the sidelines have been stained by Trump’s mud.

To my fellow Christians in particular, Trump – in his campaign rhetoric, at least – displays no evidence of being a Christian, which he claims to be. There, I said it. Forgive me if you think I am being judgmental, but I simply don’t see the fruit. This is not about waffling on various social issues on which well-meaning Christians can and do disagree. Consistently, his public demeanor is far from “Love God”, much less “Love thy neighbor as thyself.” If Trump loved anything as much as himself, we’d all be better off.

I don’t get how so many people – Christians in particular – are following like lemmings in the wake of a reality show Pied Piper – one who plays an enticing (but fundamentally deadly) tune. It is ironic that Jerry Springer, who long ago helped set the nasty reality TV tone that is emblematic of Trump’s campaign, can’t believe we would elect Trump as president.

I get that Trump is tapping into popular themes like immigration and "making America great again" – whatever that means – but the reality TV emperor has no policy clothes. In effect, Trump supporters are saying they want an angry president who doesn't know what he is doing. That is both startling and dangerous. Anger does not lead to sound foreign policy.

Trump's narcissism, lack of a verbal editor and foul speech suggest a personality disorder at a minimum. More worrisome, they expose a disturbing lack of compassion and respect for the innate value of other human beings. Add in a questionable moral compass and I truly fear the international fallout with his impulsive finger on the nuclear trigger. He’s just plain scary.

Ultimately, this column is not really about Trump. It is about me. By what ethic do I live my life and cast my vote? Do I believe that might makes right? Does the end justify the means? God forbid!

What about you?

If the Republican Party implodes (or if the Democrat Party nominates a Socialist), I do not blame the "establishment". I blame voters on both sides of the aisle who can't tell the difference between a slot machine and a voting booth. They just blindly pull the red or blue lever hoping for a jackpot. If only they could see, with that approach we are all going to lose.

Cancer Brings Out a Range of Emotions

I hate cancer.

Hate is a bad word, I know. My mother always got on to me when I said I hated something or someone. We raise our children not to hate, because hate is one of those harmful emotions and temperaments that threaten to make us less than human. Of course, kids are prone to tantrum-throwing exaggeration when it comes to hating. Lima beans, anyone?

But I am a cancer physician and I truly hate cancer. It is insidious… evil… scary.  I respect cancer - like I respect a wild animal - but I still want to kill it.

I hate some things that cause cancer. Like smoking. I don't hate the smoker, and – though some may disagree – I am not in your face about smoking. I also discourage other lifestyle decisions or factors that increase our risk of cancer (tanning, obesity, etc.). But I don't hate people. We are, after all, human. And, I know all too well that I could be next to get cancer, whether it is from something I did or did not do.

As a matter of fact, I fully expect to get diagnosed with cancer. Perhaps you should, too. I'm not being morbid, just realistic. As a man, all things being equal, my chance of developing invasive cancer at some point in my lifetime is 42%. Women have a lifetime probability of 38%. Notice, I did not say I fully expect to die from cancer. Today, the odds of surviving cancer are well in my favor. The American Cancer Society reports that over the past 3 decades, the 5-year relative survival rate for all cancers combined has increased 20% among whites and 23% among blacks. Today, roughly 7 out of 10 cancer patients are cured.

Contrary to popular belief, the overall incidence of cancer is declining. It may seem that more people we know are getting cancer, because as we age our risk goes up. The principal reason for lower rates of cancer is fewer people smoking. And the biggest factor of persistently elevated cancer risk, especially in deep East Texas, is also smoking. East Texans still smoke more than the rest of the state. I applaud Stephen F. Austin University for their recent decision to join other college campuses in going smoke- and vape-free. The current trend of vaping is a dangerous prelude to smoking for young people and needs to be stopped dead in its tracks.

As I said, I do not hate people who have cancer. On the contrary, I have a great deal of compassion for those diagnosed with cancer. Their fighting spirit motivates me. I applaud the new American Cancer Society “Advantage Humans” ad campaign highlighting traits that emerge with a diagnosis of cancer, such as courage, defiance, and anger. The ads are positive but edgy, acknowledging that raw emotions are real and battling cancer is tough.

Of course, preventing cancer – where we can – is still the best option. How? Don’t smoke; vaccinate against human papillomavirus (HPV); don’t tan; screen for colorectal and cervical cancer. Catch cancer early with mammograms and low-dose CT for lung cancer. And treat cancer appropriately per national guidelines such as those developed by the National Comprehensive Cancer Network (NCCN). Go to www.cancer.org for tremendous resources, and stay local for treatment where you have excellent facilities and the support of family and friends.

It is ok to hate cancer. In a strange way, our humanity is enhanced by hating what is evil (while also clinging to what is good, Romans 12:9). But use that hate constructively to motivate yourself to prevent, to fight, to come together, and ultimately to win.

Doctors Must Reinstill Sense of Duty

This article was originally published at Houston Chronicle http://www.houstonchronicle.com/opinion/outlook/article/Doctors-must-reinstill-sense-of-duty-6733668.php?t=d4a64f80cb&cmpid=email-premium and is reprinted here with permission from the author (me).

I am a physician. Being a doctor defines me. Whether I am seeing patients in my Cancer Center or dining at a restaurant, I am Dr. Roberts. I have expectations of myself in my role of physician, certainly. But the broader community has expectations of me, as well - expectations of competence, compassion and especially availability. Surveys and patient satisfaction scores, however, show that physicians are not meeting those expectations.

I see two broad reasons for this disconnect. One is related to how we practice medicine in the 21st century (in front of a computer rather than in front of our patients). The other has to do with what we see our role to be as physicians.

As a member of my hospital's Performance Improvement Committee, patient safety is our primary concern. Too often, though, we get bogged down in an ever-increasing slough of statistics. Some data we need to track (mortality rates, infection rates, etc.) but other data (such as whether patients think the bathroom is clean enough) are, to put it mildly, distracting.

Chasing data has become the focus of American medicine, and the individual patient has been lost in the process. On top of this is the stress and frustration of working with a bloated and perversely incentivized health-care bureaucracy that views every failure to dot an "i" or cross a "t" as fraud and abuse. Not surprisingly, not only has patient satisfaction declined, but physician satisfaction with the practice of medicine has tanked as well.

It isn't simply about computers and bureaucracy. Since I started practice in 1991, the percentage of physicians in private practice has dropped dramatically. "The New England Journal of Medicine's" CareerCenter website posted that physicians coming out of residency are increasingly gravitating toward contracted rather than private practice positions. Anecdotal reports put the desire to be employed as high as 80 percent. Various reasons are given, including the uncertain direction of health-care reform, declining reimbursement and rising overhead costs. Increasingly, physicians just want to show up at work, practice medicine (without having to deal with administrative and insurance issues), and then go home. They believe that employed positions offer a more predictable work schedule than private practice.

This growing employment model, not just among millennials, coincides with a major shift in attitude among physicians about their role - dare I say duty? - when it comes to patient care. "Becker's Hospital Review," an industry magazine, noted that physicians increasingly expect their affiliated hospitals to provide compensation for on-call coverage, which used to be an expectation of all physicians who had hospital privileges. By 2001, nearly two-thirds of health care organizations provided call pay to at least some physicians.

In our hospital committee meetings, we - the self-selected 10-percenters who are involved in medical staff leadership - bemoan the loss of a sense of citizenship among physicians. We opine on the privilege of being on a medical staff, and that there are responsibilities that come with those staff privileges. Ultimately, we just want our fellow physicians to "do what is right." That simple ethical imperative is the heart and soul of the practice of medicine. Not just doing what is expedient. Certainly not just doing what you hope (or demand) to get paid for.

I fear this is where we are in medicine today. Being a physician is no longer a profession - a calling, a responsibility - it is simply a job. The art and practice of medicine has been reduced to a series of individual transactions, each separately identified in an ever-complex system of billing codes, rather than an ongoing relationship not just between doctor and patient, but between doctor and community.

How can we recover the profession? How do we reinstill a sense of duty? Of moral obligation?

Medical schools have the initial obligation to provide a strong ethical foundation for the practice of medicine. But organizations that provide ongoing training and continuing medical education are responsible as well. The Texas Medical Board requires two ethics and/or professional responsibility CME credits every 24 months as part of a total of 48 credits required.

The Texas Medical Association, which has more than 48,000 physician and medical student members, offers 62 ethics-related CME courses ranging from communication skills and dealing with difficult patients to stress and burnout and HIPAA compliance. However, there is not a single course on basic ethical principles, which have guided the practice of medicine in Western civilization for centuries. Maybe that is because an ethical imperative to "do what is right" presupposes we know (and are willing to agree on) what "right" is.

The United States Conference of Catholic Bishops produced a document - Ethical and Religious Directives for Catholic Health Care Services - which guides all Catholic healthcare institutions, including CHI St. Luke's Health hospitals. Physicians of all faiths would be well served to read and abide by these directives, which first and foremost stem from a sacred view of human dignity. If nothing else, physicians should re-read the Hippocratic Oath, which for centuries has united physicians in a common, patient-centered cause.

Finally, we should look to physician role models around us. The Lufkin/Angelina County Chamber of Commerce hosts an annual Salute to Healthcare banquet where they honor a Healthcare Professional of the Year, Nurse of the Year, Individual of Merit, and a Lifetime Achievement Award winner. In November, I had the honor again of emceeing the event. As I announced the Lifetime Achievement award recipient, I emphasized the award is not just about showing up at work for 40 years and then retiring. That's just doing your job. What we honor each year is the extra - the above and beyond - that exemplifies a career marked by service not just to patients but to society. I hope that by honoring those who set a great example of leadership, compassion, and generosity over and above medical skill, younger physicians will be inspired to follow these examples of care beyond the dollar.

I challenge my physician colleagues, young and old alike, to "do what is right" by all patients. This is your profession, if you will still claim it.