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Health
Internet resources for what you need to know about NYC Health
Five Favorite Sites For Beginners

The Topic
"Health" refers to the health issues facing the city, touching on everything from the mayor to Medicaid to managed care to mosquitoes.
The Context
New York City is one of the biggest public health challenges in the world. With 7 million residents--over 1 million of whom are uninsured--the city has the largest number of HIV cases and the largest number of intravenous drug users in the U.S. Efforts to contain a tuberculosis outbreak that threatened the city in the 1990's have been a major success--between 1992 and 1998, the deadly multi-drug resistant cases of TB declined by over 90 percent.

New York City has 20 public hospitals which served 1.5 million people in 1998 alone. Run by New York City's public Health and Hospitals Corporation, the hospital system now has a surplus of $21 million, following years of deficits and cutbacks.

The Reporter
Maia Szalavitz is author, with Dr. Joseph Volpicelli, of "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems." She writes frequently on health, science and public policy for the New York Times, New York Magazine, the Village Voice, and other publications.

by Maia Szalavitz

Mammograms

Women concerned about breast cancer have been given a series of confusing recommendations regarding mammography screening. At one point, annual mammograms were supposed to start at 50 according to major cancer organizations; then, at 40; at another time, groups recommended a baseline mammogram be obtained at 35. Now a mammogram every other year seems as good as each year, whenever you start.

But more upsetting than these changing recommendations was the latest shift. A recent study published in the Lancet and highlighted on the front page of the New York Times suggested that mammograms may not be any help at all in increasing cancer survival. The authors analyzed the research for a respected international organization, the Cochrane Collaboration. This created an uproar -- which is of particular concern to New Yorkers because there are several areas here where women are at particularly high risk.

These include Manhattan's Upper East Side and Nassau and Suffolk counties in Long Island. African-American women and affluent white women both have elevated risk levels-- and researchers don't yet know whether genetic or environmental factors like pesticides and pollution are more important.

Within weeks of the Times story, the American Cancer Society, the American Medical Association -- basically every involved cancer organization in the country including the National Cancer Institute of the National Institutes on Health and the U.S Preventive Services Task Force of the Health and Human Services Administration -- publicly supported mammography and played down the research.

So what's going on here -- and why is mammography data so confusing? Often, in scientific controversies, one can safely stick to the position taken by prominent medical organizations. But here, though all the cancer groups and agencies lined up on one side, the other side isn't just a few lone dissidents.

The Cochrane researchers represent an international project aimed at putting practices on a sound evidentiary footing. Though medicine appears to be scientific, it is widely known that there are numerous common practices which were introduced without proper study and have continued despite being proven useless or even harmful.

Further, the National Cancer Institute is more skeptical than the other organizations. One of its advisors, Dr. Daniel Berry of the M.D. Anderson Cancer Center, told the Associated Press that the Institute's website will be updated to say that "there is uncertainty regarding the benefits of mammography."

Dr. Robert Smith, director of cancer screening for the American Cancer Society lays out the pro-mammography case. He says the authors of the Lancet study, in reviewing the trials, 'threw out too much evidence and uncritically embraced [the two studies that showed no evidence of an effect for mammograms]" He also points to reviews done in countries that provide national health care and have limited budgets for it.

"The scientists in the UK have looked at the data and mammography is health policy in the UK. Sweden evaluated the evidence and mammography is health policy in Sweden. It's offered in Italy, in the Netherlands, the list goes on and on. We've looked at these studies and we don't see these flaws. We think [the reviewers] are wrong."

One part of the controversy may be a difference in perspective between epidemiologists who look at populations as a whole and individual doctors and patients. Kay Dickersin, associate professor of epidemiology at Brown University Medical School and co-director of the New England Cochrane Center, says, "There's probably a culture clash between [those who focus on particular patients] and epidemiologists who have been saying for a long time that this data is complex and filled with uncertainties. If you are treating individual patients and think even one could have breast cancer and it's possible to detect it early, you want to detect it as early as possible and it's worth almost anything," she says.

"You might have to screen 2500 people and you may have many false positives but to that one woman, it's priceless." Of course, for the women who have "false positives" -- some 80 percent suspicious mammograms do not reveal breast cancer-- there's another issue. First, there's the anxiety of thinking you may have breast cancer.

Second, there's the chance of undergoing an unnecessary biopsy -- or even an unnecessary lumpectomy or mastectomy, which can occur when certain tumors called "ductal carcinoma in situ (DCIS)" which frequently do not get worse, are found and removed. Surgery itself carries a risk of mortality.

Smith says that such unnecessary treatment should not be blamed on mammography. If a woman gets a mastectomy for these types of tumors, it is "a significant harm," he says, but the problem is not the mammogram but failure to individualize treatment.

Both sides agree that better testing is needed. But until it is developed, argues Smith, it would be crazy not to use mammography, the current gold standard.

After all, breast cancer deaths have declined 20 percent in the last 10 years (less in New York City -- between five and 19 percent depending on which statistics you use).

While most researchers on both sides believe this is due to treatment advances, some of the drop could be due to early detection helping treatment succeed.

So where does this leave women considering when to have a mammogram? Dickersin emphasizes that large population studies like those reviewed do not say anything about particular risk groups -- so women with a family history or other risk factors, for example, will probably want to have mammograms more frequently and earlier.

Also, given the current uncertainties, a woman's own fears and preferences take on more weight. Says Dickersin, referring to DCIS statistics. "You could say that if we detect DCIS there's a one in seven chance that you will die of it if we do nothing. For a woman with young children, that risk may be seriously high. But an older woman might decide to take her chances."

How numbers are presented also matters. Smith cites the movie "Annie Hall," where Woody Allen complains that he and the character played by Diane Keaton almost never have sex' "three times a week." Diane Keaton is seen simultaneously, saying "we're always having sex -- three times a week."

"Take the time to think these things through," says Dickersin.

While the mammography debate may sound right now like a semi-blind choice between the possibility of not finding a curable tumor in time and the possibility of having unnecessary and disfiguring surgery, a woman's own level of risk for breast cancer and feelings about it can help her and her doctor make the best decision.


Maia's Favorite Five Sites For Beginners:

  • New York City Department of Health - Includes health alerts (including West Nile info), information on restaurant sanitary conditions and information on various health-promotion programs.
  • New York State Department of Health - More health data for New Yorkers including information on how to sign up for Child Health Plus and Family Health Plus-- the insurance programs for those who are presently not covered by other plans.
  • Medscape - This site, aimed at doctors, allows you to search Medline, the database of medical journals, for free. Abstracts of most journal articles are available for free as well. Once you have some basic knowledge about a condition you are researching, you can look here to get a sense of what is going on in terms of study in the area. There is a companion consumer-focused site, CBSHealthWatch, which is linked.
  • American Cancer Society - Half of all Americans will face cancer at some point in their lives-- and the New York and Washington-based American Cancer Society web site provides a wealth of information for those dealing with the disease. Includes links to other major cancer sites and resources.
  • AIDS Information - A sort of "AIDS central" for New York city with links to major HIV/AIDS organizations and information sites.


Other Recommendations:

  • Quackwatch - Debunks medical scams and inflated claims made by "alternative" medical practitioners.
  • AccentHealth.com - A consumer health information site, affiliated with CNN.
  • Citizen Action - Healthcare is one of the primary focuses of this New York advocacy group. Includes information on New York's health plans for low income people lacking insurance.
  • Oncolink - An incredible research resource for cancer patients and others concerned about this disease.
  • National Alliance for the Mentally Ill - An organization of advocates for people with mental illness which includes information on treatment and support for various disorders like depression, bipolar disease and schizophrenia.
  • Insure Kids Now - Information on New York state's insurance program for poor kids and information on other state's policies, from the federal government and the governors' association.

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Gotham Gazette is published by Citizens Union Foundation and is made possible by support from the Robert Sterling Clark Foundation, the John S. and James L. Knight Foundation, the Altman Foundation,the Fund for the City of New York and donors to Citizens Union Foundation. Please consider supporting Citizens Union Foundation's public education programs. Critical early support to Gotham Gazette was provided by the Charles H. Revson Foundation, Rockefeller Brothers Fund and the Alfred P. Sloan Foundation.

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