Whitney Palmer

Healthcare. Politics. Family.

Aggressive Breast Cancer in African-American Women: Investigating the Genetic Link

Published in the 2009 University of North Carolina at Chapel Hill School of Nursing Research Chronicle

African-American women experience less breast cancer than women of other ethnicities. However, the breast cancers these women develop are often more invasive and aggressive. Assistant professor Theresa Swift-Scanlan is investigating the reasons behind this disparity and believes the answer lies in understanding epigenetic modifications to women’s DNA and how they are affected by lifestyle behaviors and environmental exposures. Epigenetic modifications are molecular level changes that alter gene expression without altering the primary sequence of DNA.

According to Swift-Scanlan, African-American pre-menopausal women are more likely than women of other ethnicities to develop basal-like breast cancer, a tumor subtype that does not have receptors for estrogen or the growth factor Her2. Basal-like tumors are resistant to effective therapies that target these receptors, such as tamoxifen and herceptin. The end result is that these tumors are very difficult to treat and are associated with increased morbidity and mortality.

According to previous data, Swift-Scanlan said, basal-like tumors occur in white women and other ethnic groups at all ages, just at a lower frequency than in African-American pre-menopausal women. Differences in the frequency of this tumor subtype appear to be due to varying distributions of risk factors

Asst. Prof. Theresa Swift-Scanlan conducting research into the epigenetics of breast cancer in her research lab.

across ethnic groups. Risk factors for basal-like tumors include not breastfeeding and larger waist-to-hip ratios. Unlike other breast cancer subtypes, having more children at a younger age appears to increase rather than decrease risk for basal-like breast cancer.

The Susan G. Komen Foundation awarded Swift-Scanlan a three-year, $450,000 Career Catalyst in Cancer Disparities Award to study gene methylation in basal-like breast cancer and four other tumor subtypes. The grant funds her efforts to determine whether DNA methylation – which can silence genes by changing the way the DNA is packaged within the cell – in concert with facts known about breast cancer subtype risk factors, could unearth ways to reduce mortality from the disease among African-American women. She also has funding through a National Institutes of Health Career Development Award.

Swift-Scanlan also hopes to identify genes that, when methylated, could contribute to early disease detection and risk assessment for all women.

“I hope that this research will help women in the decision making process,” she said. “Deciding what to do after a breast cancer diagnosis is a very personal and profound choice. Having this knowledge could help providers assist women in making the best decision for them while avoiding the problem of over- or under-treating the disease.”

Swift-Scanlan will analyze breast tissue samples and clinical data from at least 160 African-American women enrolled in the Carolina Breast Cancer Study, 80 of whom are pre-menopausal and 80 who are post-menopausal. Her main collaborators are genetics associate professor Charles Perou at the Lineberger Comprehensive Cancer Center and epidemiology professor Robert Millikan at the School of Public Health.

March 23, 2010 Posted by | Family, Healthcare | , , , | Leave a comment

Nursing Isn’t Always Recession Proof

Published in the Spring 2010 Carolina Nursing magazine

When the University of North Carolina at Chapel Hill School of Nursing BSN Class of 2009 began classes in the fall of 2007, the nursing shortage was in full swing. These students happily studied and completed their clinical rotations, confident in the knowledge that they would be employed when they finished their degree.

Then, suddenly everything changed with “the Great Recession.” Now, the job market that needed them – one where they had their pick of hospital and location – was shrinking, and the jobs that had been plentiful were evaporating. The situation did not improve by the time they received their diplomas.

“We definitely had many more new graduates applying for jobs than we had jobs that we could fill with new graduates,” said Mary Tonges, senior vice president and chief nursing officer for UNC Healthcare. “Retention has been way up, turn over has been way down, and we have more experienced nurses applying for the same jobs that new grads are seeking.”

The economy is keeping nurses in the workforce longer, causing many to rethink early retirement plans or career-changing.

At first glance, the much-touted nursing shortage seems to have disappeared. But, according to Tonges, the healthcare industry can’t breathe a sigh of relief just yet – the shortage will return as soon as the economy begins to turn around. The need will be especially great in North Carolina where both an aging and growing population will require nurses to provide care.

The temporary overstock of practicing nurses hasn’t put a damper on application rates, and class admission is as competitive as ever. Many students are struggling, however, because there is not sufficient scholarship support to help them complete their education. This is problematic because, as history tells us, people traditionally look to education and re-education when the economy slumps.

Beverly Malone, chief executive officer for the National League for Nursing

According to Beverly Malone, chief executive officer of the National League for Nursing (NLN), the economic downturn is touching nursing education in several secondary ways. Bleeding state budgets have cut money to state-supported higher education institutions, making it harder for administrators to attract quality nursing faculty with competitive salaries.

But the faculty environment at the SON is different, said professor Marilyn Oermann. She said she believes the School has largely escaped the faculty shortage.

“The nursing faculty shortage is certainly a problem nationwide,” Oermann said. “However, we have been fortunate not to experience that problem here. I truly feel that both our excellent reputation and the strong pull of living in a beautiful area like Chapel Hill have saved us this hardship.”

Regardless of whether a school currently has a faculty shortage, Malone said that the current economic climate gives the nursing profession an excellent opportunity to strengthen existing relationships, as well as grow new ones.

“I believe whole-heartedly that, in this economy, it is time for those of us in nursing to stand together. Deans have to support their faculty, and the rest of us in the profession must support our deans,” Malone said. “This is a difficult time, so it’s important for support to go in both directions.”

Frustrations might exist elsewhere, but nursing is still a growth industry in North Carolina, said David Kalbacker, director of public information for the North Carolina Board of Nursing. While many healthcare environments are seeing less turnover, fewer vacant jobs and fewer retirees, there are still hospitals that offer opportunity to new graduates. For example, he said, Cape Fear Valley Health System in Fayetteville, N.C., extended employment offers to 55 new graduates over the past year.

Unfortunately, a lack of qualified instructors isn’t the only problem students face, Malone said. Many older nursing students finding themselves forced to choose between a nursing degree and paying their mortgage. According to a 2002 National Health Foundation study, 20 percent of BSN students and 18 percent of associate degree students drop out of nursing school. Of those, nearly 42 percent leave due to financial hardship. In addition, foundations have also circled their wagons, keeping a tighter hold on their grant award dollars than they have previously.

But, according to Kathy Moore, the director of the School of Nursing Office of Admissions and Student Services, applications to the SON have remained strong. Undergraduate applications have remained stable, and graduate applications jumped 60 percent over the past academic year. Overall, that’s good news because more advanced practice nurses are needed to care for our aging population.

There is a hope that some of these students will continue on to pursue a doctorate with the goal of becoming nurse faculty, fostering the production of quality, baccalaureate-trained nurses. Data from a 2002 NLN survey revealed that 75 percent of the current nursing faculty will retire by 2019, with approximately 1,800 leaving their positions each year. The NLN estimated that 10,000 master’s students graduate annually, and, of those, 15 percent would need to become faculty simply to maintain the current faculty status quo.

The faculty shortage impact, however, is a long-ranging problem. Recent graduates have felt the most immediate impact from the economy, however, as they have been pushed to look beyond their first job choices and even consider leaving the region to gain employment.

“In previous years, students could come to me and say, ‘I want a job with these particular characteristics,’ and they would probably find it,” Moore said. “Now, however, they’re having to look beyond those strict parameters and rethink the career they envisioned for themselves.”

Despite the current economic conditions, there is hope on the horizon that nursing education will begin to regain some of the support has lost, Malone said. As part of the ongoing talks on healthcare reform, the Obama administration is floating discussions about loan forgiveness programs that have vanished to a great extent. The U.S. Congress is also weighing in, considering the reauthorization of both Title VII and Title VIII that have aimed at growing geographic, racial and ethnic diversity in the health professions.

“We see opportunities in nursing education,” Malone said. “With each cloud there there is a silver lining. The door will open wide again for nursing, and there will be many opportunities in healthcare and nursing education.”

March 23, 2010 Posted by | Healthcare | , , , , , , | Leave a comment

Media Portrayal of Nursing: Ready for a Close-Up

Nurses are saints. No, they’re angels. Clearly, they’re hand-maidens for doctors. Wait, all the really good nurses plan to go to medical school some day. At least that’s what we see on television and in the movies.

The truth is that TV shows or movies do not accurately portray what nurses do and the value their caring and scientific knowledge bring to healthcare environments. What we see most often in entertainment media are doctors who perform the real-life work that nurses do. This misrepresentation creates the appearance that nurses are secondary, non-essential players in healthcare settings, assigned to changing bed linens and taking temperatures. And, unfortunately, television and film is where most people form their perceptions and attitudes about the nursing profession.

The conversation about on-screen nursing characters has been around for years, but the recent launch of three new shows that have a nurse as the main character – Nurse Jackie, HawthoRNe and Mercy – has opinions flying once again.

“Whether it’s TV, films, billboards, magazines or music, the media historically depicts nurses incorrectly – they just don’t know who nurses are,” said Sandy Summers, executive director of Truth About Nursing, a media advocacy organization striving to improve the public’s understanding of nurses’ role in healthcare. “These portrayals leave people with the impression that nurses don’t do anything interesting or important.”

What nurses really do each day is clearly dramatic enough for television, said Summers, who is a Nurse Jackie supporter, otherwise directors and writers wouldn’t have doctors perform those tasks on camera.

For decades, the inaccuracy has incited national nursing organizations and nursing advocates to protest the way the entertainment industry depicts nurses. They have repeatedly petitioned these organizations to make changes. Their most ardent request is that writers produce scripts with nursing characters who reflect the high level of competency necessary to maneuver in a complex healthcare environment, without assigning the negative traits.

But many advocacy groups spend so much time rejecting nursing characters

Diana Mason, editor-in-chief emerita of the American Journal of Nursing

that aren’t perfect that they miss the ones that present some of the best qualities nurses can have, said Diana Mason, editor-in-chief emeritus of the American Journal of Nursing and endowed chair at the Hunter–Bellevue School of Nursing at the City University of New York. A nurse character doesn’t have to be a faultless person to exhibit both a fierce devotion to protecting patients and a high level of knowledge.

“Often, these organizations aren’t media savvy, and they are unable to separate out the nursing image that is often needed to make entertainment intriguing,” Mason said. “They are right to boycott some shows that have a solo nurse character who decides to go to medical school, but we shouldn’t demonize the nursing characters that care deeply for their patients or shows that tackle the real issues that nurses face.”

And the nurses who have appeared on screen have, indeed, changed over the years. When nurses first graced film and television, they were either self-sacrificial heroines or love interests. Today, in comedies and dramas, they wear scrubs and have strong personalities. There is even a new trend to create “dark nurse” characters – those that are violent, possessed and tormented. But, with few exceptions, they still play peripheral roles, said David Stanley, senior lecturer in the School of Nursing and Midwifery at the Curtin University of Technology in Perth, Australia. Stanley analyzed 280 movies produced worldwide between 1900 and 2007, observing stereotypes and unflattering portrayals. He published his results in the United Kingdom-based Journal of Advanced Nursing.

David Stanley, senior lecturer in the School of Nursing and Midwifery at the Curtin University of Technology in Perth, Australia

Misrepresentations on television are likely to have a more profound effect on the public’s perception about nursing than movies, Stanley said.

“Television brings characters into the living room,” he said. “The viewer is more likely to associate it with reality than what they see in a movie. They tend to recognize movies more as entertainment.”

But the character’s strength or commitment to patient safety alone doesn’t make them palatable to practicing nurses, and the effect on the public can be negative, said Courtney Rawls, a practicing nurse in Washington, D.C. Rawls has spent many hours talking with students about how the entertainment industry portrays nurses.

“Television shows and movies feel like they have to put drama into what we do, so they never accurately portray our work,” she said. “What we do is valuable, but it’s not glamorous, and adding all the drama makes the public more confused. These misrepresentations even make it hard for me to explain my job to my own mother.”

Nurses can’t depend on the entertainment industry to get it right on its own, though, said Cindy Saver, president of CLS Development Inc., a company that provides knowledge-based services for nurses. Saver is a registered nurse who has published many articles on nursing topics in various nursing publications, including Nursing Spectrum and Nurse Week. Practicing nurses must be proactive and voice their opinions and desires, she said, recommending that nurses flood producers with e-mails and letters, contact companies that advertise during certain shows and express displeasure and pen opinion-editorial pieces that can appear in newspapers.

“Most importantly, nurses have to go to the media with suggestions for improvements and be willing to acknowledge positive things in shows and movies,” Saver said. “And, when asked for our input and feedback, we have to be willing to provide it.”

Clearly, opinions about the entertainment media’s portrayal of nursing are still brewing hotly. Any one character is unlikely to satisfy everyone in the profession, at least one thing is true: scriptwriters are now beginning to see merit in including a nurse in any show about healthcare.

March 23, 2010 Posted by | Healthcare | , , , , | Leave a comment

Hospitals Choose Care Over Compensation When Treating Immigrants

Published in the February 2005 AAMC Reporter

David Pate, M.D., chief medical officer at St. Luke’s Episcopal Health System in Houston, faced an almost impossible decision several months ago. A 19-year-old woman, who was neither a U.S. citizen nor a legal immigrant, desperately needed a heart transplant but could not afford the operation or any required aftercare. He could deny the procedure, thus allowing the woman to die, or approve the surgery and absorb the charges.

David Pate, M.D., chief medical officer, St. Luke's Episcopal Health System

Ultimately, Dr. Pate authorized the procedure, saving the woman’s life. The hospital’s uncompensated costs topped $1 million. The hospital, affiliated with Baylor College of Medicine and the University of Texas Medical School at Houston, always tries to do the right thing, he said, but sometimes weighing the financial considerations versus the medical and ethical issues is a complex situation, especially when the patient is in the country illegally.

“These are very complicated issues when you ask yourself if this money should have gone to care for people in our own community,” he said. “But I have daughters this age, and I wanted to help this woman who had her whole life ahead of her.”

St. Luke’s and other academic medical centers across the country encounter similar moral and financial dilemmas frequently. The burden of providing healthcare for undocumented immigrant patients who likely cannot pay for services is particularly acute in six states: Arizona, California, Florida, New Mexico, New York and Texas. Confronting the many pitfalls in this field is difficult, but teaching hospitals deal with them in a uniform way. They simply provide the care.

Under the Medicare Modernization Act, the federal government allotted $25 million over four years for the care of undocumented immigrant who enter hospitals through emergency rooms across the country. The money is divided among states, but additional money is available to the six states with the highest illegal immigrant populations. More specific instruction on how to allocate the funds have not yet been published.

Patient Overload

But hospitals in the affected states still face a laundry list of challenges when providing healthcare to illegal immigrants. Emergency rooms are often clogged with patients who cannot receive care elsewhere, and facilities rarely receive reimbursement for any emergency services or aftercare rendered to them. Some physicians shy away from working in these hospitals because they will not be compensated, and physicians who see patients must battle with the language barrier.

Undocumented immigrants receive the same type and quality of care in St. Luke’s emergency room as any other patient would, whether they come in themselves, transferred from another hospital or are brought in by a documented family member, Dr. Pate said. Despite the high financial loss, illegal immigrants only constitute a minority of the hospital’s patients.

Providing this initial care is simple. The difficulty arises when patients need extensive, costly follow-up care. Even though St. Luke’s is a tax-exempt facility and has a health amount of charity dollars, Dr. Pate said he is careful not to spend exorbitant amounts of money on uninsured patients who could receive adequate care elsewhere. Consequently, physicians transfer patients who need more long-term or chronic care to other hospitals in the area.

Patients with more complex cases occasionally find themselves in the same situation in Los Angeles, said Patrick Dowling, M.D., chair of the University of California-Los Angeles Family Medicine Center affiliated with the UCLA School of Medicine. A “safety net” system of county service clinics functions as the medical provider for the more than two million Los Angeles resident who lack health insurance. An overwhelming majority are undocumented immigrants.

Prohibitive Care

Consulting a physician for preliminary care is sometimes the easy part of an illegal immigrant’s travels through the U.S. healthcare system. If they need any additional care, such as medications, X-rays or CAT scans, seeing a specialist or a consultant is virtually impossible.

“Getting adequate services for these individuals is the hard part,” Dr. Dowling said. “The cost of care is just too high.”

But the majority of undocumented immigrants navigate life in America without using the healthcare system to a great degree. Young, healthy men in search of jobs constitute the largest portion of the illegal immigrant population in Los Angeles area, Dr. Dowling said, and they rarely visit the hospital for medical services.

In addition, young women of Latino heritage — the largest immigrant population in Los Angeles — do not require extensive medical care either. As young mothers, their babies tend to be some of the healthiest in the hospital, requiring little additional services, Dr. Dowling said. If they did require additional care, however, a California law mandates Medicaid coverage for any pregnant woman regardless of immigration status.

Despite the fact that the majority of undocumented immigrants are young and healthy, it is estimated that the price tag associated with providing care costs billions of dollars each year. The exact amount of uncompensated care for undocumented immigrants at the national level is unknown.

The search for quality healthcare is not the primary motivation for individuals to come to the United States. The main draw is still employment, said Dan Griswold, director of the Center for Trade Policy at the Cato Institute. While immigrants seek work in the United States to support relatives in their native country, their own medical needs arise infrequently.

“When undocumented immigrants seek medical services, it is usually incidental,” Griswold said. “They generally come in because of an accident or an illness they’ve ignored for a while. And because they don’t have health insurance, they’re going to go too the emergency room.”

Fragile Ground

At this point, with no health insurance and low wages, illegal immigrants are no different from under- and uninsured American citizens living below the poverty line, Griswold said. High medical bills could make life in America frightening for some illegal immigrants, but a recently stalled government proposal could have made seeking much-needed healthcare an even riskier activity.

Last year, the Centers for Medicare and Medicaid Services (CMS) published a requirement that all hospitals ask patients directly about their immigration status when providing care. In a letter to CMS, the AAMC expressed its strong opposition to the requirement, arguing that it would cause fewer undocumented immigrants to seek treatment. The proposal raised numerous concerns, and the agency received so many letters in protest that it was eventually dropped.

Forcing immigrants to divulge their legal or illegal status could erupt into a public health problem in the future, said UCLA’s Dr. Dowling. The fear of deportation could be so strong that undocumented immigrants would forego medical treatment until they become a danger to the public. By then, they will require more expensive services than they would have if they went to the emergency room initially.

Dr. Pate at St. Luke’s said undocumented immigrants could also stop seeking healthcare if they left a particularly bad situation in their native country.

“I suspect there would be a chilling effect for many individuals,” Dr. Pate said. “If the scenario of going home is so bad, many may decide that it is better to be sick in the United States than risk returning to their country.”

Unfounded Fears

But Greg Pivirotto, president and chief executive officer of University Medical Center in Tucson, Ariz., said any concerns about scaring undocumented immigrants away from healthcare simply by asking them whether they are in the country legally are unfounded.

University Medical Center, which is affiliated with the University of Arizona, has tracked patients’ immigration

University Medical Center in Tucson takes on an added responsibility caring for immigrant patients without compensation.

status for 20 years with no deleterious effects, he said.

“All of this ‘to do’ about scaring immigrants away is a lot of baloney,” he said. “It’s not illegal to ask, and you don’t even have to do it directly. We do it, and we’re still delivering care.”

In fact, a year ago, the Tucson facility implemented a policy that requires patients, including undocumented immigrants, to provide an address to start a payment plan before leaving the hospital. If illegal immigrants do not give the hospital this information, the administration waits seven days and then sends their name and available contact information to immigration services, Pivirotto said.

Immigration officials do not depart the individuals, but they do put an “unpaid medical bills” marker on the immigrant’s file that will show up in case he or she ever applies for documents in the future.

The threat of having their names in a file with the immigration authorities has not stopped undocumented immigrants from seeking healthcare at University Medical Center, however. In the 12 months since enacting the payment policy, the facility has doubled the amount of care it provides for illegal immigrants, and the total uncompensated care cost jumped from $6 million in 2003 to $12 million in 2004.

“Everything comes back to finances, and some doctors don’t want to come in the middle of the night if they won’t get paid,” Pivirotto said. “Fortunately because we’re in a university environment, many doctors still work here because they believe in what they’re doing and are less drive by the bottom line.

March 23, 2010 Posted by | Healthcare, Politics | , , , , | Leave a comment

   

%d bloggers like this: