I wish u knew… Healthcare Affordability Act

Tim Hampshire

“You can get me to talk about tort reform for three hours,” said Dr. Neha Vapiwala.

As a student of law and politics, out of my element with most of the people I interview, my ears perked up. Some people like to talk about truths, some about reality television, and some about situations that are truly screwed up. Dr. Vapiwala and I, on this dispiritingly hot afternoon in July, discovered that we reside together in this third camp. How sad for us.

As happenstance would have it, prostate cancer is the point where all the rivers of the underworld converge. Dr. Vapiwala, who deals mostly with prostate cancer (by radiating it,) is familiar with the particular challenges of it.




First of all, it’s common. Very common. One in six men will experience it. Most grocery store lines contain one or two inevitable cases. This is disheartening. But it’s not too disheartening, because many prostate cancers present at early stages, and they don’t always spread. Men can live happily and actively with them. We can catch them with PSA screening tests. But PSA screening tests tend to catch cancers that wouldn’t do much harm in the first place, so men are led to undergo dangerous or toxic therapies that are much worse than their cancers could ever be. So the United States Preventive Services Task Force (USPSTF) issued a decree stating that PSA screenings should not happen early in men. They are not statistically worthwhile, or not as much as we thought.

This introduces the impression that prostate cancer is not dangerous. This is compounded by the availability of “active surveillance” as a treatment option, in which nothing at all is done to the patient, but the doctor routinely monitors the infected prostate. But it is dangerous. Men die of it every day. And it’s wildly, frustratingly, abusively common. And “big pharma” doesn’t tend to fund drugs that can treat it early on; the money is allocated to the vicious end-stage diseases. And the awareness groups that represent it are not as organized as they are for breast cancer. People don’t pay attention to it. Then they get it.

Oh my god.

Dr. Vapiwala drops her knowledge bombs with biting sarcasm. She’s understandably sick of the dog-and-pony show that is the world of clinical oncology. She does noble work. But the world makes it hard.

Her solution to the screening issue is the bane of all lawmakers, who enjoy order and rigidity: it has to be determined on a case-by-case basis. “Helping patients make decisions along the way is what this country should be about; it’s what having the healthcare system that we have should be about,” she said. If you’re a person who should be screened, who wants to be screened, and you ask for screening, she thinks, you should get it. “They’re already in the candy store,” said Dr. Vapiwala, referring to patients who come to Penn Medicine seeking treatment options or screening. “And now you’re telling them they can’t have the candy.” It really should be all about the patient’s prerogative. In an ideal world, anyway.

Unfortunately, it just isn’t. Even if the prevalent attitude in the medical community were that all men should get PSA screenings, not all men could afford to access the high-level quaternary care required to treat the cancer that the screening would catch. Dr. Vapiwala thinks that the recently upheld Affordable Care Act could have a positive impact on that problem. By making primary care more available to everyone, there will (again, ideally,) be a broader base of educated citizens who know where to go and whom to ask when they’re feeling like something might be wrong. If that is followed by a commensurate increase in the number of medical students who go into primary care, then there could be an elegant solution to the screening problem: a world in which every doctor is not overspread, and can pay attention to the needs of every patient, and can refer only the ones who truly need to be screened to the big centers like Penn Medicine. That would narrow the funding demands of tests like the PSA, and it could possibly be included in most insurance plans. I think John Lennon had a song about that world.

Still, there’s no reason why we shouldn’t be hopeful. There are people in the system who recognize the importance of screening. Maybe Chief Justice John Roberts is one of them. Dr. Vapiwala is definitely another. At the end of the day (in fact, at the beginning and throughout the duration of every day,) she’s doing whatever she can to kill cancer.

“I see men who are 40 and 50, with jobs and with families, with really bad prostate cancer. And if they were not screened, I don’t even know. They’d be pretty much dead. So I don’t know how to reconcile that with what the community needs, and what the population needs, and what the government needs,” she said. “I just know that if that person was sitting in my clinic, and nobody had tested them, we’d be shaking our heads.”

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