Cancer: The Big C

Aliases: cancer

Cancer is an obvious choice for this month’s theme (economics); its costs are so great, they almost need no introduction. As the second leading cause of death in the US1, it has touched the lives of nearly every American. Obviously, the cost of cancer is incalculably high for the patient, but it does not stop there. The painful challenge of this disease extends outward, from family and friends to the medical professionals charged with combatting it.

While the emotional toll on doctors and nurses that work with cancer patients is impossible to measure, there are other, more quantifiable costs associated with their work. One is malpractice. Radiologists, who use imaging technologies (i.e. X-ray) to diagnose and treat illnesses such as cancer, have a high rate of malpractice claims, both in the US and abroad, and it’s increasing. This leap in litigation reflects both the inherent difficulties of radiology, and the rise in its use5. The majority of these suits are related to cancer cases; in Italy, over half of the diagnostic radiology claims between 1993 and 2005 concerned breast cancers and mammographic technique. The predicted rate of litigation against Italian radiologists is 10.5/1,000, which amounts to 1 claim per radiologists per 10 years of work4.

One survey of radiologists across three American states found that about half had a previous malpractice claim. The same study showed that malpractice suits have a negative psychological impact on the doctors involved; about 81% of respondents described the claim as very or extremely stressful. Nearly 1/3 (35.3%) had considered withdrawing from mammogram interpretation entirely because of malpractice concerns. The effects of these experiences spilled over into their practice. More than ¾ (76.4%) were concerned about the impact of claims on mammography practice, and over half (58.5%) indicated that their concern moderately to greatly increased their recommendations for breast biopsies (sampling cells or tissues), a more invasive diagnostic procedure. Yet, their fears may be overblown: the responding radiologists’ estimate of their future malpractice risk was much higher than the actual historical risk. And there doesn’t seem to be a downside for patients, as medical malpractice experience and concerns were not associated greater false-positive rates in cancer diagnosis3. Nonetheless, malpractice claims add another cost to cancer’s tally: the price of human error.

cancer
To err is human.

Cause: Although we think of cancer as one illness, it is really a category of ailment that encompasses a whole suite of diseases. But while there are a wide range of cancers, the fundamentals are the same. Cancer is caused by the development of uncontrollably dividing cells that can infiltrate and destroy normal body tissue. These abnormal cells are caused by a DNA mutation, which can be genetic (inherited), stimulated by the environmental (i.e. smoking or radiation), or a combination of the two. Cancer can spread throughout the body, but it takes time to develop, which is why most people are diagnosed after age 651. Men are most commonly affected by prostate cancer (128.3/10,000 men contract it), breast cancer is the most common type in women (122/10,000), and lung cancer has the highest fatality rate in both men (57.9/10,000) and women (37/10,000)2.

Consequence: Because there are so many forms of cancer, there are myriad symptoms, and they largely depend on the part of the body that is affected. Many are also symptoms of other less serious conditions. Some common symptoms include: a lump or area of thickening that can be felt under the skin, unexplained weight change, skin change, persistent cough, unexplained muscle or joint pain, fevers or night sweats, or indigestion or discomfort after eating1.

Cure: While there is no hard and fast cure, there are extensive treatment options. Treatments can be broken down into three types: primary (treatments that remove or kill cancer cells, i.e. surgery), adjuvant (treatments that kill cancer cells that might remain after primary treatment; i.e. chemotherapy or radiation), and palliative (treatments that relieve the side effects of other treatments or the cancer itself). Treatment options include surgery, chemotherapy (which uses drugs to kill cancerous cells), radiation therapy (which uses radiation, such as X-rays, to target cancerous cells), and hormone therapy, among others. Unfortunately, many cancer treatments have significant side effects, including: pain, fatigue, nausea, weight loss, diarrhea or constipation, and neurological or hormonal changes or issues. Palliative treatments include alternative medicine options, such as acupuncture or massage, which may offer some relief. As ever, prevention is key, and there are an abundance of screenings tests for cancer, ranging from physical to imaging to biopsy1.

References

  1. Cancer. Mayo Clinic. 2 January 2014. Web. 12 April 2015.
  1. Cancer prevention and control. Centers for Disease Control and Prevention. 6 April 2015. Web. 12 April 2015.
  1. Elmore, J.G., W.E. Barlow, G.R. Cutter, C.J. D’Orsi, R.E. Hendrick, L.A. Abraham, J.S. Fosse, & P.A. Carney. 2005. Does litigation influence medical practice? The influence of community radiologists’ medical malpractice perceptions and experience on screening mammography. Radiology, 236:37-46.
  1. Fileni, A., N. Magnavita, & L. Pescarini. 2009. Analysis of malpractice claims in mammography: a complex issue. La Radiologia Medica, 114:636-644.
  1. Magnavita, N., A. Fileni, P. Mirk, G. Magnavita, S. Ricci, & A. Cotroneo. 2013. Malpractice claims in interventional radiology: frequency, characteristics and protective measures. La Radiologia Medica, 118:504-517.

Image source: Creative Commons, http://www.bbc.com/news/health-29920157

The Cost of Mental Illness: Side Effects

In developed countries, mental illness causes more disability than any other disease group, including cancer. In 2004, 25% of adult Americans reported having a mental illness in the previous year2. As a consequence, the cost of mental illness is astronomical; it was approximately $300 billion in 2002 in the US alone2, accounting for 6.2% of US healthcare spending. That amounts to about $1,000 a year for every American5. However, if that price is the prescription for mental illness, it’s got plenty of side effects, because the sum, while staggering, only represents a fraction of the actual cost of mental illness. The true tally is much higher and harder to calculate, and includes the toll of mental illness on society, the ill and their families.

Social side effects

Mental illness and resulting discrimination impair the abilities of the ill to participate in society, and rob communities of their contributions. The cost of the work hours and wages lost due to the absence of the ill is referred to as productivity loss. In the UK, depression results in productivity losses that are 23 times as great as the associated healthcare costs, and is the most important cause of absenteeism from the workplace4. Mental illness can also relegate the suffering to the outskirts of society, with severe consequences. In the US, 22% of the incarcerated and 1/3 of the adult homeless population are mentally ill5, and it is estimated that for every £1 of healthcare spending on those referred for addiction treatment in the UK, £3 is spent on them by the criminal justice system, and £10 by the victims of crime4. The mentally ill are also less likely to be hired or be rented to, and more likely to be falsely charged with a violent crime3.

mental illness
For reference: this is what $1 billion in $100 bills looks like.

This social segregation has insidious effects. Working is not just a means to an economic end; it also imparts self-esteem to the employee, and expands their social network4. The benefits of social inclusion are sorely needed by the mentally ill, and could aid in their treatment and recovery. Being ostracized may actually prolong illness or contribute to relapse by lowering self-worth, perpetuating the cause of unemployment and exclusion, and creating a terrible feedback loop.

Personal side effects

While the cost of mental illness to society is very dear, it pales in comparison to the price paid by the afflicted and their families. The mentally ill shoulder physical, emotional, and social burdens as a result of their illness. Serious mental illnesses, such as schizophrenia, cause poor personal care and lifestyle choices (e.g. a high fat diet), which can negatively affect overall health and self-esteem, and act as barrier to social acceptance. The seriously mentally ill smoke 44% of cigarettes used in the US5, and are more likely to be overweight; 40-60% of people with schizophrenia are overweight or obese, which in turn makes them more likely to suffer from diabetes and cardiovascular disease7.

Unfortunately, seeking help isn’t without its own consequences. The treatment for mental illness often includes medication that can have serious side effects. Antidepressants can cause gastrointestinal (e.g. nausea, vomiting) and neuropsychiatric (e.g. drowsiness and dizziness) issues, and negatively interact with other drugs8. Antipsychotics can contribute to weight gain, and those that do put the patient at a greater risk for type II diabetes. Some antipsychotics may also increase the risk of movement disorders, cataracts, and cardiac dysfunction, such as arrhythmias7. Depression and schizophrenia, as well as their respective treatments, are also associated with negative sexual effects, meaning they impair sexual function and satisfaction1.

Stigma and its corollaries, prejudice and discrimination, are pervasive issues for the mentally ill, and mental illnesses have become increasingly stigmatized over the past few decades. These interactions depend on an ‘us’ and ‘them’ mentality perpetuated by stereotypes, and a social, economic, or political power imbalance between the groups. With that dynamic in place, the mentally ill are subjected to both everyday and structural discrimination. Stigma can also be internalized by the ill, a phenomena called self-stigmatization. Stigma strains familial ties; 20% of respondents to a family survey reported lower self-esteem and tenser relationships with other family members as a result of stigma3. The impact of stigma is profound, and can cause the ill to shun treatment, in order to avoid the label of mental illness and its resulting social repercussions6.

The social backlash against mental illness is contingent in part on the idea that it is rare. It isn’t; it’s incredibly common. And while the burden of its symptoms and their treatment is unavoidable, the sting of stigma is not. Acceptance and understanding of mental illness can lighten the load. Mental illness will never be painless, but we might be able to make it a little less expensive.

References

1. Baldwin, D, & A Mayers. (2003). Sexual side-effects of antidepressant and anti-psychotic drugs. Advances in Psychiatric Treatment, 9:202-210.

2. CDC Mental Illness Surveillance. Centers for Disease Control and Prevention. 2 December 2013. Web. 27 April 2014. http://www.cdc.gov/mentalhealthsurveillance/faqs.html

3. Corrigan, PW. (1998). The impact of stigma on severe mental illness. Cognitive and Behavioral Practice, 5:201-222.

4. Knapp, M. (2003). Hidden costs of mental illness. British Journal of Psychiatry, 183:477-478.

5. Insel, TR. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165(6):663-665.

6. Rüsch, N, MC Angermeyer, & PW Corrigan. (2005). Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. European Psychiatry, 20:529-539.

7. Üçok, A, & W Gaebel. (2008). Side effects of atypical antispychotics: a brief overview. World Psychiatry, 7(1):58-62.

8. Wilson, K, & P Mottram. (2004). A comparison of side effects of selective serotonin reuptake inhibitors and tricyclic antidepressants in older depressed patients: a meta-analysis. International Journal of Geriatric Psychiatry, 19:754-762.

Image source: http://www.moneybagsfull.com/2010/08/what-does-1-billion-dollars-in-cash.html