Ruminations

Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Wednesday, May 24, 2017

Consumer Caution Advised in Energy Drinks

"The energy drink industry claims that their products are safe because they have no more caffeine than a premium coffee-house coffee."
"However, energy drinks also contain a proprietary 'energy blend', which typically consists of stimulants and other additives. Some of these ingredients [including taurine and guarana] have not been FDA-approved as safe in the food supply, and few studies have tested the effects of caffeine consumption together with these 'novelty' ingredients."
"On top of that, energy drinks are highly marketed to adolescent boys in ways that encourage risky behaviour, including rapid and excessive consumption. As a result, emergency room visits by young people in connection with energy drinks are rising."
Dr. Jennifer L. Harris, Rudd Center for Food Policy and Obesity, University of Connecticut
The multiple ingredients in different brands of energy drinks need more scrutiny, researchers say.
The multiple ingredients in different brands of energy drinks need more scrutiny, researchers say. (Canadian Press)


Over 500 energy drink products are now on the market; their popularity is manifest by the extent of their sales, and in lock-step with their popularity is the allied phenomenon of increasing visits to hospital emergency centres, and even deaths attributed to their consumption. A 32-ounce container of an energy drink is now being linked with potentially harmful blood pressure and heart function changes beyond alarming and owing not only to the caffeine in those drinks but other key ingredients present in them.

Consumers like energy drinks. And people who convince themselves that anything that is freely available on the market and that suits their lifestyle cannot be a threat to their health, simply will not believe that these drinks indeed can very well pose a threat best avoided. The manufacturers of the energy drinks, after all, attest to their perfect safety, in itself persuading consumers there is no threat to their health in their consumption. But the growing body of evidence appears to firmly point in the opposite direction.

Caffeine up to 400 mg, reflected in the consumption of up to five cups of coffee is considered to be a safe daily dose by the U.S. Food and Drug Administration. Energy drinks mostly contain caffeine, and plenty of it, but it is the other ingredients in those drinks about which the level of safety is largely unknown, concluded a study team whose results were published in the Journal of the American Heart Association.

A research team led by Sachin A. Shah of David Grant Medical Center on Travis Air Force Base along with the University of the Pacific in Stockton, California, set out to compare physical alterations resulting in a group of 18 healthy men and women after they had consumed an energy drink and after another drink with a similar dose of caffeine, lacking any other ingredients had alternately been consumed.

The energy drink given the test subjects contained four ounces of sugar, several B vitamins, and a proprietary 'energy blend' of taurine and other ingredients most often linked to drinks like Monster Energy, Red Bull, and 5-hour Energy. And that energy drink also contained the obligatory 320 mg of caffeine, analogous to what would be contained in four cups of coffee. Alternately another drink was given the participants which held only the 320 mg of caffeine, nothing additional.

The research team then measured the study participants' blood pressure along with measuring heart electrical activity for 24 hours following the consumption of the drinks. Using an electrocardiogram (EKG) for the heart measurement activity, it was discovered that a change identified as QTc prolongation, a condition associated with life-threatening irregularities in the heartbeat, was present post-energy drink consumption, but not after consuming the caffeine beverage.

Blood pressure was seen to increase by about five points after the energy drink was consumed, and in comparison less than a one point increase was noted after the test subjects drank the beverage containing caffeine only. In addition, blood pressure remained in that elevated state for the following six hours. The study points out that healthy individuals are not threatened by these changes, but people with particular heart conditions would do well to exercise caution with these energy drinks.

hi-energy-drinks-teen-852-c
Just as adolescents are taught to drink alcohol responsibly, they could receive a similar message about energy drinks, pediatricians say. (Jack Dempsey/Associated Press)

"The energy drink amount tested by the U.S. researchers in this study was equal to twice the amount that is permitted to be labelled in Canada for maximum recommended servings per day."
"Health Canada's recommended maximum amounts are based on all of the ingredients of energy drinks, not just the caffeine."
Canadian Beverage Association

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Tuesday, May 23, 2017

Preventing Cancer

"To see Sandra age and then quickly lose her cognitive ability, her speech, her memory, her ability to walk and care for herself ... It was all gone very quickly."
"To me, it's ass-backwards. You have all these millions of dollars of cancer treatment stuff, and then you have a dinky little cupboard [tiny, understaffed office], basically, for [cancer] prevention."
Alan Huggett, Prince George, British Columbia

"It's why the cancer problem is as big today as it was when [President] Nixon declared the war on cancer."
"We haven't won that war because we have been fighting on the wrong front, or at least we haven't been fighting on the front where we could have a major impact."
"Curing cancer gets votes. There are no grateful people saying, 'Thank you for preventing my bladder cancer'."
Jack Siemiatycki, cancer epidemiologist, University of Montreal
Sandra Huggett
Sandra Huggett and her daughter Lia in 2014: Photo provided by Alan Huggett

Mr. Huggett of Prince George, B.C. is mourning his wife, stricken with lung cancer, diagnosed at stage-four at a point where the malignancy had already spread to her kidneys and bones. A year after her diagnosis the cancer had invaded her brain and she was in palliative care. She lingered for another few months and died before her 56th birthday, leaving behind her husband and their two young daughters. Sandra Huggett had never been a smoker.

After her shocking diagnosis a test for radon was conducted on their family house. That test revealed that she had been exposed to radon gas, a colourless, odourless gas found naturally throughout Canada. Her home was revealed to have three and a half times the level of radon considered to be safe. Radon, though considered to be the second greatest cause of lung cancer after tobacco, is not on most people's radar; most have never heard of it, have no idea what its exposure can cause.

And its presence and what it can cause is considered to be an avoidable source of cancer. Sandra Huggett's husband Alan and their daughters Lia and Kimberly still live in the family home in Prince George. But it no longer presents a dire health threat. The presence of radon has been for all practical purposes eliminated, and at a fairly modest cost. Retrofits that ensured the radon could no longer penetrate the house and affect the lungs of the remaining three of the Huggett family cost less than $1,500.

Research into cancer and treatments for cancer is a multi-billion dollar industry. Yet work hindering the disease from invading vulnerable humans to begin with appears to be treated as a casual afterthought, with barely five percent of the total expenditure on research and treatment going toward prevention.  According to a 2015 federal survey less than three percent of homes have been tested for the presence of the deadly gas.

As well, according to Dr. Siemiatycki, holder of the Guzzo Cancer Research Society chair in environment and cancer, Canadian scientists researching the causes of cancer have dwindled to half of their number involved in that work in 1985. Dr. Siemiatycki points out that the Canadian Institute for Health Research, the major federal medical-science body providing funding, is complacent over providing one to two percent of its cancer budget to prevention.

One day, he believes, scientists will have succeeded in identifying preventable risk factors for all cancers, once the tide turns and sufficient resources are allocated to ensure that outcome. Some experts feel that 40 to 50 percent of malignant cancers are now avoidable, as the result of lifestyle or environmental influence, ranging from sun exposure to obesity.
cancer cell
Dr. Siemiatycki feels that most cancers in all likelihood have both a non-preventable, genetic aspect along with an aspect relating to the individual's behaviour or environmental exposure. Tobacco, recognized as the most powerful carcinogen, relates to behaviour as well as exposure. Yet roughly ten percent of heavy smokers will end up with lung cancer, pointing to a hard-wired genetic propensity for acquiring cancer, working alongside the habit of exposure.

But science must repeatedly prove the theories that arise to convince doubters. In 2015 the journal Science published a paper written by Cristian Tomasetti and Bert Vogelstein, two Johns Hopkins University researchers who hypothesized that the lung is 11 times likelier than the brain to be affected by cancer, related to the frequency at which stem cells divide, leading to resulting DNA mutations. Their conclusion was that a random process is involved relating to the development of tumours adduced to stem-cell divisions.

Two thirds of cancer risks, according to these two researchers, can be attributed to "bad luck". Dr. Tomasetti, a bio-statistician, recommends a sharper focus on early detection to allow patients diagnosed with cancer an enhanced opportunity for survival. Inherited, environmental and random triggers represent the trifecta he and his research partner identified in their study. "This really is a paradigm shift and it has strong implications for research direction", he said.

The wholesale plummeting of smoking rates from the 1960s forward has saved 800,000 lives in the United States alone on an annual basis, accounting for most of the drop in  cancer mortality, according to a 2012 U.S. study. A new study involving 300,000 Canadians is currently underway where subjects are to be closely followed over time, with blood tests and questionnaires, in an effort to obtain data on why some people contract cancer and others don't.

Estimates by Cancer Research U.K. suggest that societal obesity reduction has the potential of preventing up to 187,000 cancer cases a year in Britain; that eating more fruit and vegetables would reduce cancer numbers by 15,000 annually; consuming less alcohol 13,000 fewer cancer cases; and more conscientious sun protection would result in 11,000 fewer cases yearly of skin cancers.

Cancer prevention

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Monday, May 22, 2017

Statistical Bias and Perceptions on Religious Devotion

"Caring for others versus personal fulfillment, those are two very different value constructs. And the relationship between them and religiosity is really significant."
"What this survey proves is that having a faith, being part of a faith community, seems to propel people in the direction of developing higher levels of compassion or caring."
"I find it noteworthy that we have significant divisions in this country on some moral issues, and those divisions seem to be heavily correlated with religious belief and membership in faith communities."
"We like to sometimes paint ourselves as this country where, unlike the United States, which has deep value differences, we are all sort of linked arm-to-arm on all issues. Actually, that's not true."
Angus Reid, founder/chairman, Angus Reid Institute

"On the one hand, in contrast to the prevalent public narrative that religion is private and it doesn't mater, it's quite clear that for the vast majority of Canadians, it does. Over half say, 'Religion is actually shaping my identity and my decisions'."
"On the other hand, that engagement is a relatively thin engagement."
Ray Pennings, executive vice-president, Christian think-tank Cardus
While some Canadians might not attend religious institutions like church regularly, many of them have religious views and personal faith.
While some Canadians might not attend religious institutions like church regularly, many of them have religious views and personal faith. (Chris Corday/CBC) 
 
On Mr. Reid's part, the recent survey his firm conducted allied with Faith in Canada 150, appears to validate for him a foregone conclusion -- that religious faith makes us better people, more aware of the needs of others, willing to inconvenience ourselves for the sake of aiding others, and being more receptive to the need to be charitable and generous and caring. On Mr. Penning's part, that validation has a bitter core; that not enough members of the broader public have committed to religious adherence and those that have do so in a tepid manner. Religion or not people who live fulfilled lives themselves tend to be more generous with others; it's called simple human decency.



This project took a year to gauge the beliefs of Canadians who took part in the poll to arrive at a consensus on their religious practices. People responding to the questions were divided into four distinct categories identifying them  as a) non-believers on to b) religiously committed devotees regularly attending places of worship. Responding to the choice of two alternatives representing their idea of "the best way to live life", 53 percent chose "achieving our own dreams and happiness" rather than "being concerned about helping others".

When religion was brought into the equation, it was found that 67 percent of those committed to religion chose helping others, while 65 percent of non-believers selected the personal pursuit of happiness. Something seems to be missing here, and that is the common-sense understanding that people who are happy and satisfied are more likely and able to extend themselves to helping others, while those who are miserable are usually so caught up in their situation they are  most often incapable of giving aid to others.

Across different regions of Canada the question elicited different responses, with the Province of Quebec scoring the highest proportion of people selecting for self-fulfillment at 65 percent, while Alberta was second at 54 percent and British Columbia came next at 43 percent. Elsewhere in Canada, a majority of respondents selected giving aid to others; Saskatchewan proving the most generous at 59 percent.

Oddly enough, Quebecers were traditionally the most bound to Catholicism before undergoing a sweeping change where the Catholic Church stepped back during the Quiet Revolution as formerly devout parishioners rebelled against the stranglehold on life of the Church. And Quebec is the province whose administration is the most broadly social-welfare inclined, so Quebecers are accustomed to having things done for them, not to doing for others. Religious devotion still plays a private, not a public role in the province, despite which Quebecers are parsimonious when it comes to funding charities.



A total of 2,006 Canadian adults took part in the survey and responded to a series of questions with clear moral overtones. Pollsters concluded that the two groups representing the religious spectrum, both privately faithful and religiously committed were likelier to agree that:
  • Canada should accept fewer immigrants and refugees;
  • They would be uncomfortable if a child planned to marry someone from a different cultural or religious background;
  • There should not be a greater social acceptance of people who are LGBTQ (lesbian, gay, bisexual, transgender, queer);
  • Preserving life is more important than people's freedom to choose on issues like abortion and doctor-assisted death;
Which hardly shines a socially g enerous light on religious adherents; rather their socially conservative attitude bespeaks issues of intolerance and a lack of openly generous impulse. Another question was where the poll led participants to select the statement they felt reflected their personal views:
  • People are fundamentally sinners and in need of salvation; or
  • People are essentially good and sin has been invented to control people.
The essential goodness of people was selected by two thirds of those pooled while the religiously committed, providing roughly one-fifth of the survey group, felt by 73 percent that people are fundamentally sinners. The concept of right and wrong in absolute terms or a vacillating conception was posed as well with a large majority of 68 percent finding that right or wrong "depends on the circumstances", while close to 66 percent outright rejected that moral questions' outcome differ for different cultures.



Religiously committed were the most likely to claim universal rights apply to the entire human race, at 74 percent. And they represented people stating their faith to be of primary importance to their personal identity at 54 percent, and to their day-to-day lives at 55 percent. Of course religion, as does culture and heritage, shapes an individual's values and colours the way others are viewed; human beings are programmed by nature to cleave to those who share like commitments and values. Which should not deter them from viewing those outside their groups as worthy, but that too reflects basic human nature.




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Sunday, May 21, 2017

Living With Cancer

"If you're surrounded by people who are telling you, 'you've got to fight', you think, 'How about I rest today and fight tomorrow? How about, 'I'm scared and I don't want to battle'?"
"And some people talk about just feeling ready to let go. They've battled it for too long. But that's unacceptable. That's seen as failure. That's seen as losing."
"I always get these looks, deep in my eyes -- 'how are  you doing'?"
"It's the people who get kind of stuck there, and I find that difficult. ...I'm not there any more, and I guess that's part of the chronic thing. People who have had cancer for a long time, I'm sure they don't want to live as if their identity is, 'I'm a cancer person'."
United Church Minister David Giuliano, 20-year cancer patient

"Who wants to go to war with themselves? How is it ever helpful to think of oneself as a victim who was randomly attacked and now you're trying to kill your assailant in order to survive?"
"Some cancer patients may perceive themselves as a soldier going to war. But surely not all do."
Radiation oncologist Edward Halperin, New York Medical College

"Battle language is everywhere in my profession. [The message conveyed is] that there's a choice to fight or give up."
Dr. Seema Marwaha, internal medicine specialist, Toronto

"But cancer isn't an enemy -- it doesn't have an ideology, it doesn't have a political agenda."
"It comes from within us; it's part of the history of humanity. We rarely cure cancer unless we can cut it out. But things like long-term remission and disease control -- these are the goals."
"We're getting better at controlling cancer for longer periods of time."
Dr. James Downar, critical care and palliative care physician, University Health Network, Toronto 

"There are periods where the cancer needs treatment and periods where no treatment is given."
"Part of the challenge also is doing enough, doing sufficient visits and scans so that you have a good handle on what's happening so that you can adjust and adapt and intervene, but not overburden somebody with scans."
"This is all quite new, this whole notion of kind of being in-between [treatments]. It's a bit of a limbo state, sometimes."
Dr. Jonathan Sussman, radiation oncologist, McMaster University
cancer cell
At the present time, an estimated 800,000 cancer "survivors" exist in Canada, some living with cancers which never quite recede on a permanent basis, like lymphomas of a certain type, leukemia, and sometimes invasive beast cancers. This is cancer hovering, always in the background, seeming to recede, then returning years later. Low-grade lymphomas, for example, cancers of the lymphatic system, are among those which arrive, depart, return.

At one time melanomas were always lethal when they spread, having an average survival rate of a year, two years. At the present time, immunotherapies succeed in placing a robust proportion of patients with metastatic melanoma in a state that is controlled "where the thing is quiet, it's not really advancing", explained Dr. Sussman. But cancer is not an invited and a valued guest, and when it does decide to invade, the psychological burden is a heavy one when people are plagued by fears of a returning or progressing cancer.

The language of cancer, the nomenclature used, is an understandable one; after all this dread disease has decided to invade someone's body, threatening anguish, pain and death. And when people are constantly encouraged to put a positive spin on their fears  of what that cancer is doing to them, by 'fighting' it, an insidious state of mind can creep into the situation, where patients accede to brutal treatments or "maximum tolerated doses" of chemotherapy, despite the hope of survival being so dim.

If patients become so committed to 'fighting' when it's long past time to struggle with the disease, that they refuse palliative care to ease symptoms and alleviate the mind which in and of itself is capable of slightly prolonging life, the demand for aggressive treatment among others whose type of cancer would in all probability never threaten their existence, but leaves them subjected to pain and trauma represents two polarized states and outcomes, both linked to 'fighting' and 'defeating' cancer.

People who are encouraged to 'fight' and to remain 'positive' are likelier to succumb to emotional distress while putting on that proverbial brave face. Over one thousand Canadian women with breast cancer, part of a research program out of the University of Manitoba, revealed that those who considered their disease in 'enemy' terms and 'punishment' suffered higher levels of depression and anxiety three years later.

According to some experts the future holds out the promise that it may be possible to conceptualize a time when cancer, Ike controlled diabetes or HIV, becomes a chronic, manageable disease. Some medical scientists feel that if total destruction of cancer remains elusive, an alternative arises where tumour cells are contained, when it becomes possible to "box-in tumour cells with a discrete-focused strategy of containment."

Meanwhile, the drive to destroy cancer cells unremittingly leads, according to those experts, to survival of the fittest in the sense that the "moderate" cells, sensitive to chemotherapy are destroyed at the same time that the "extremist" cells are left intact, preparing to morph into even more deadly tumours. Whereas a middle ground between "appeasement and Armagedden is containment".

Survival of at least five years after diagnosis represents the reality for about 60 percent of cancer patients overall. That, in comparison to the 1950s, when fewer than 25 percent of cancer patients would survive their bout with cancer. As for most women going through breast cancer diagnosis and treatment, "the breast cancer is not going to be their length-of-life-defining illness", Dr. Sussman emphasizes.

Cancer

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Friday, May 19, 2017

A Living Surgical Nightmare

"Someone was inside me, ripping ripping me apart."
"It was excruciating. It was burning and burning and burning."
Lynn Hillis, 54, Cancer patient, Toronto

"She described trying to move, open her eyes and scream but being unable to get the attention of the doctors."
Judge Kendra Coats, Toronto

"The impact was just profound. It started with the nightmares."
"It's been nine years [since her own 'awakening' during surgery] and I still have nightmares. I still wake up screaming."
Donna Penner, Winnipeg, former surgical patient
In the first ruling of its kind in Canada, a judge says an anesthetist was at fault for a Toronto woman's nightmare experience of waking up in the midst of surgery.
SunMedia    In the first ruling of its kind in Canada, a judge says an anesthetist was at fault for a Toronto woman's nightmare experience of waking up in the midst of surgery
 
Surgeons and anesthesiologists are increasingly aware that on occasion a patient under sedation in preparation for surgery can 'awaken' and be entirely aware of what is happening as an operation proceeds. Because of anesthetic immobilizing them physically and breathing tubes inserted through their mouths since the autonomic breathing is interfered with when anesthetic is infused into a human body, the newly-awakened patient, while aware of what is transpiring and feeling horrible pain, cannot communicate with the surgeons. It is only after the surgery that the surgical patients can describe the horrors they experienced.
 
New research appears to have concluded that this 'awakening' phenomenon almost exclusively impacts on morbidly obese patients resulting from the difficulties anesthesiologists experience in calculating how much anesthetic to administer; just enough to keep them sedated; not too much so that there is danger blood flow may be restricted to the heart and brain. Most anesthesiologists end up calculating the amount of anesthetic required by body weight, and with obese patients those calculations tend to discount body fat, just weight minus the fat out of concern of administering too much.
 
In Lynn Hillis's experience the accidental surgical 'awareness' left her vulnerable to physical helplessness, and being forced to be aware of everything taking place during her surgery, including the incalculable pain she experienced. Suddenly, halfway through her operation resulting from her diagnosis of endometrial cancer where laparoscopic surgery to remove her uterus, ovaries and fallopian tubes was taking place at Toronto General Hospital, she awoke.
 
What she experienced during that 2008 operation forever changed her life; she was diagnosed with severe trauma; post-traumatic stress disorder. Her experience of being frozen by paralytic drugs leaving her unable to communicate with the surgeons focusing on her surgery was the stuff of nightmares. And it is calculated that roughly one thousand patients annually in Canada undergo some version of being 'awake' during surgery when anesthetic fails; sometimes fleetingly, sometimes throughout the surgery.

While waking during surgery is not common, professor of anesthesiology Dr. Eric Jacobsohn says it needs to be taken seriously.
While waking during surgery is not common, professor of anesthesiology Dr. Eric Jacobsohn says it needs to be taken seriously. (Jean-Sebastien EvrardAFP/Getty Images)

Ms. Hills decided to sue the two anesthetists who took part in her surgery; one a staff doctor who handed over her care halfway through the surgery to a "fellow"; an advanced trainee, present for the entire surgical procedure. Ms. Hillis was able to recount the entire proceedings of the surgery, including what the surgeons transmitted to one another as they spoke and how the surgery proceeded. And while the doctors' lawyers insisted that anesthetic was properly administered, the judge hearing the case concluded that Dr. Reza Ghaffai had erred in failing to increase the intravenous Propofol sufficiently.

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Thursday, May 18, 2017

Goldilocks: Not Too Much, Not Too Little: Just Right

"Using the lean body weight formula [in sedating a patient for surgery through the application of anesthetic] probably isn't the best method to dose your propofol in the morbidly obese patient, because it results in under-dosing."
Dr. Jean Wong, anesthesiologist, Toronto Western Hospital

"I have been practising for over 25 years -- so over 25,000 anesthetics -- and so far have not had one patient mention awareness as a problem."
"Having said that, obesity is becoming more common and more severe all the time. No one really knows how to adjust the doses of drugs for large patients."
"The problem affects all drugs. Are bacterial infections adequately treated if obese patients are given too little antibiotic? Do obese people die of heart attacks if they are given too much or too little of various medications?"
"No one knows."
Dr. John Friesen, anesthesiologist, University of Manitoba
The rue dose of propofol required is certainly higher than the lean body weight but a littler lower than total body weight
The right dose of propofol required is certainly higher than the lean body weight but a littler lower than total body weight: Carl de Souza/AFP/Getty Images  

Now, it seems, the obese have yet another health impact to worry about: during surgery, the application of anesthetic insufficient to take into account their morbid body weight having the potential to lean toward their 'waking up' at a most inconvenient time throughout the surgical process when in theory and in practise, they are imagined to be fully sedated, unaware of what is happening to them.

One woman's experience was narrated as part of a large audit of "accidental awareness during general anesthesia" published in a British review that discovered a disproportionate number of people had reported their unfortunate experience with the terrifying phenomenon -- all of whom were obese patients. And now, a new Canadian study published in the Canadian Journal of Anesthesia for which Toronto Western Hospital's Dr. Wong was the senior author, has identified a failing in the standard formula calculating the amount of anesthetic required to induce unconsciousness in surgical patients.

Even while there is an ever-growing demographic of people with morbid obesity, defined as a BMI of 40 or more, anesthesiologists base induction doses of the most commonly used anesthetic, propofol on lean body weigh represented by an obese individual's body weight, subtracting the fat quotient. There is a reason for that; caution. Due to the fear that by using total body weight to calculate the amount of propofol needed could lead to overdosing the extremely obese. Serious complications can ensue with such an overdose; a rapid drop in blood pressure, decreased blood flow to the heart and brain.

Dr. Wong's study found that the use of lean body weight for calculating doses in the morbidly obese results in an "insufficient" depth of anesthesia in 60 percent of the cases studied. That lack of depth leads to accidental awareness because of the failure to deliver enough anesthetic to the body. Researchers randomly assigned sixty patients undergoing bariatric (stomach-shrinking surgery) to one of two groups.

The first group had doctors dosing propofol using the lean body weight calculation. For the second group doctors used a unique device known as a bispectral index monitor (BIS) to measure brain activity which determines how the anesthetic has succeeded in sedating the patient. The monitor uses he information to translate to a number from 100 (person is wide-awake) to zero (no brain electrical activity). Once the number dropped to 50, the propofol infusion  was stopped.


Eighteen out of thirty people remained "responsive" after the initial propofol dose, requiring additional infusion before a sufficient level of sedation was achieved. In the group monitored by the bispectral index monitor of the brain on the other hand only one patient remained "responsive" when the target of BIS 50 was reached. Propofol is highly fat soluble making it more difficult to reach sufficient levels in specific target receptors in the brain to properly sedate people entering surgery.

Numerous reports of obese patients reporting "falling asleep", then waking while a breathing tube was being inserted, or alternately at the beginning of the surgery, were documented in the largest prospective study on accidental awareness by Dr. Jaideep Pandit, consultant anesthetist at Oxford University Hospitals. Dr. Pandit felt the results of this new study demonstrates "that the true dose of propofol required is certainly higher than LBW (lean body weight) but a little lower than TBW (total body weight)."

And then, there is this: most frequently people of "normal" weight exclusively take part in drug trials.

Oxygen mask
Thinkstock

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Wednesday, May 17, 2017

Coping With The Financial Fallout of Cancer

"It's a huge issue [loss of income and costs related to cancer care]. For middle-class Canadians and working-class Canadians a cancer diagnosis is like standing on thin ice, and you only hope you can get back to work and cover your bills before you go under."
"Those [government] benefits just expire too soon for a lot of people."
Gabriel Miller, Canadian Cancer Society

"It's something I'm not proud of [filing for personal bankruptcy], something I never thought I'd do. I've always been a proud, stand-up individual. But I had no alternative ..."
"You're not bringing in income, bills are mounting, [creditors] are not compassionate and understanding. They want their money."
Lawrence, (last name withheld),Toronto real estate agent, 56

"The thing that keeps me up at night is, if I do need a drug or some treatment of some sort, will we have the funds to cover it?"
"And if we have to sell our house, is that even a reasonable thing to do? Probably, I would just go quietly."
Deb Maskens, advanced kidney cancer patient, Guelph, Ontario

"People will deal with different stresses, they will have financial stress or problems with health."
"When you throw everything together all at once, there comes a point where you say 'I just can't do it any more'."
"You need to be able to breathe."
Monica Pope, 51, breast cancer patient
cancer cell
In Canada, a growing body of research, along with interviews with patients, point to the fact that despite universal health care coverage for everyone, a diagnosis of cancer has an enormous drag on anyone's future. Going beyond the dread diagnosis and the accompanying psychological stress and physical pain of surgery and treatment, there is the looming threat of financial insolvency caused by the inevitable prolonged income loss and costs related to cancer treatment.

Drugs required on an ongoing basis, not administered in a hospital, are paid for by the patient. If there are expenses related to travel on top of the drug costs the end result is a devastating financial burden at the very time when fear rules while the cancer is being treated and the final outcome remains unknown. An estimated one in six bankruptcies are caused by the fall-out of health problems, and many of them relate to cancer.

If there are economic options that come into play they are the draining of savings for retirement for example, the re-mortgaging of homes, and the base alternative of going on welfare. Undergoing cancer drug treatment at home, not in hospital, means it is patients who personally must pay the cost of expensive medications in some provinces. Once the fear of a dramatically shortened lifespan reflected reality, now however, patients live longer post-treatment and federal and provincial income support programs prove inadequate.

Some people have disability insurance that they rely upon to help them with their growing health-related expenses while there is a hiatus from their work, yet some insurance companies if they can prove a pre-existing condition is involved, refuse to honour the policy. Even though in Canada oncology treatment comes without a personal charge under the universal health care system, all other costs associated with treatment are at the patient's expense.

According to a 2002 survey by the Canadian Partnership Against Cancer, two of every five people diagnosed with cancer go off their work schedules for a minimum of six months while receiving treatment. The diagnosis of  cancer and its after-effects impact on caregivers, some 60 percent of whom must cut work hours or leave their employment, according to a Lung Cancer Canada Survey. Canadian patients' families experience incomes plummeting by 26 percent according to a 2010 McMaster University study.

While some employees in Canada have access to workplace disability benefits, an estimated seven million Canadians have none. Those who qualify can count on Employment Insurance kicking in, but sickness benefits last for fifteen weeks at most, providing 55% of normal salary. As for the Canada Pension Plan, cancer patients run into problems qualifying for disability benefits to people under 65 under CPP which kicks in at a rate of $1,300 monthly. And welfare provides less than that figure, as an alternative.

According to Ilene Shiller, a manager at Wellspring, a Toronto-based cancer charity, some people are so "shocked" at the prospect of their income falling so dramatically they delay treatment so they can remain at work longer. Quebec, Alberta and British Columbia pay for all cancer medications, Ontario and the Atlantic provinces provide less coverage for home medications typically costing thousands monthly. Ontario does have a catastrophic drug coverage program for patients under 65 with no workplace drug plan but patients are required to contribute four percent of their income yearly.

The nightmare for people facing a cancer diagnosis and attempting to balance all their needs as a patient with a drug protocol will continue to become an acute social problem as cancer drugs by 2020 taken at home are expected to impact 60 percent of patients. And while the Canada Health Act requires hospital-administered drugs to be covered by medicare, provinces are not expected to fund those medications self-administered in the home.

cancer bankruptcy

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Tuesday, May 16, 2017

Levelling The Funding Field

"Everyone has the same goals in mind. The same goals are impacting cancer, preventing cancer, treating it better, improving the quality and length of life of people who are affected by cancer."
"Everyone knows it will not be a single project done by a single agency that will get us there."
"An alliance such as CCRA [Canadian Cancer Research Alliance] is helpful, but it can't mandate a change in focus or direction or targeting."
Elizabeth Eisenhauer, head, Department of Oncology, Queen's University School of Medicine

"Why did it [decision to target the most under-funded cancers] take so long? Tough question."
"It could be that you don't have capacity -- maybe you don't have researchers working in that area who have been trained in and thought about the disease. It could be that the disease has been addressed in a way that just hasn't made any difference."
"Ten years [to see research results] in the lifespan of the human species is nothing. It's less than a blink of an eye."
Jack Siemiatycki, professor of epidemiology, Universite de Montreal

"We have way too many funding vehicles."
"Politicians like to create new things. I think one thing we should be doing is consolidating, taking a look at how many agencies we have."
Jim Woodgett, cancer researcher, director of research, Lunenfeld-Tanenbaum Research Institute

"It would change the face of cancer research and cancer care in this country [his foundation's plan for collaboration and data-sharing]."
"Canada has some of the best researchers in the world. They try to share ideas, but there's just not a great infrastructure to allow it to happen."
Britt Andersen, executive director, Terry Fox Foundation
Cancer

In the United Kingdom, a single charity is responsible for funding most of the research undertaken in Great Britain. It makes good sense that if a single entity is held responsible for distributing funding for vital research it has at its disposal all the necessary data it needs for decision-making. That little-to-no redundancies occur. That administrative costs are kept to a relative minimum, unlike a whole horde of funding bodies operating on their own with little communication between them. And the fact that some types of cancer have funding momentum behind them while others, perhaps more deadly do not, because the better-funded ones have vigorous self-interested campaigns.

A single funding body would be, in theory neutral. It would base its decisions on funding equality leavened by the understanding that some deadly cancers do require a greater focus, awareness and research dollars. As things stand at the present time in Canada, none of this is adequately addressed. And though it is well known that some campaigns have been hugely successful in focusing public notice and fund-raising because the kind of cancer it represents benefits from a sturdy level of support from survivors, while other cancers with an abysmally low survival rate have no one to help publicize its deadly effects and call for more funding, the inequality resists change.

The fragmented funding in Canada has been the subject of much conversation and debate in the medical research community. Basically, it is a situation where competition for scarce research dollars triumphs over common-sense funding for all cancer research projects impacting the lives of the public, particularly those whose morbidity remains high but which languishes because their incidence rate fails to resonate in the public eye and ear without the aggressive publicizing of survivors, because there are none.


The Canadian Cancer Research Alliance (CCRA) was born in the early 2000s. It has succeeded in ensuring a 60 percent increase in funding projects, while partnering with agencies from 2008 to 2011. Despite which, that funding disparity continues to exist. One area in which little has been done is research into cancer prevention, surely as vital a goal to achieve as cures. But prevention is allocated roughly two percent of total funding. Funding evaluations of research looking into the effectiveness of anti-smoking campaigns in high schools, for example.

Professor Siemiatycki puts this kind of situation down to agencies having a preference for research more likely to produce results in shorter time-spans, a success story that can be placed in an annual report to convincingly demonstrate to donors or taxpayers how well their investments have succeeded in producing needed answers to such vexing problems.  He cites the kind of research that focused on the realization that smoking causes cancer, a more lengthy project, taking over a decade to come to its conclusion.

Additionally, universities and hospitals have a tendency to take on staff researchers in fields attractive to funding which alone guarantees that disproportionate funding for grant proposals, reflecting a result that comes with over-funded, over-studied areas. The Canadian Institutes of Health Research's Institute of Cancer Research announced a grant program recently targeting the most under-funded and deadliest of cancers; lung, pancreas and liver, which sounded timely. But researchers were concerned over the CIHR's newly introduced grant review process meant to simplify and standardize applications.

And then, what was meant to move things along, led instead to chaos. And that led to over 1,200 scientists signing an open letter to protest the changes, delivered to the CIHR last summer, convincing it to return to the face-to-face peer review of old. And as far as Jim Woodgett is concerned, there are simply too many researchers competing in a shrinking funding pool, with too many funding agencies administering that pool.

The recent focus by the public on the announcement last summer by Tragically Hip frontman Gord Downie, of his diagnosis of brain cancer too far advanced to treat, was viewed as a potential catalyst to enlist a greater public reaction in research funding, augmenting limited research dollars and directing them toward high-mortality-rate cancers. The current reality is that vigorous campaigning by women has resulted in a disproportionate share of funding going toward breast cancer research, where the survival rate has ascended year-after-year.

“While breast cancer is the highest funded, it is the most common non-skin related cancer in women and also can behave differently based on the features of the disease,” the Canadian Breast Cancer Foundation said. “It is precisely the research funding that has been allocated thus far that has allowed incredible breakthroughs in the treatment of breast cancer… and has resulted in the improvement in mortality that we see today.” - See more at: http://news.nationalpost.com/features/the-fundraising-complex#sthash.Y3PoBs6A.dpuf
“While breast cancer is the highest funded, it is the most common non-skin related cancer in women and also can behave differently based on the features of the disease,” the Canadian Breast Cancer Foundation said. “It is precisely the research funding that has been allocated thus far that has allowed incredible breakthroughs in the treatment of breast cancer… and has resulted in the improvement in mortality that we see today.” - See more at: http://news.nationalpost.com/features/the-fundraising-complex#sthash.Y3PoBs6A.dpuf
“While breast cancer is the highest funded, it is the most common non-skin related cancer in women and also can behave differently based on the features of the disease,” the Canadian Breast Cancer Foundation said. “It is precisely the research funding that has been allocated thus far that has allowed incredible breakthroughs in the treatment of breast cancer… and has resulted in the improvement in mortality that we see today.” - See more at: http://news.nationalpost.com/features/the-fundraising-complex#sthash.Y3PoBs6A.dpuf

Cancer

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Monday, May 15, 2017

Saving Newborn Hearts

"Some [newborns] are not diagnosed [with critical congenital heart disease] in hospital right away and they may come back to medical attention in very poor condition [increasing both risk and stress]."
"Stories of babies being rushed back to emergency rooms in distress, stories like Jimmy Kimmel's, where they are thrilled with their healthy newborn baby and the next thing they know their baby needs life-saving treatment and surgery -- screening will help turn those stories into things of the past."
"What we do know from the coroners' reports is that every year there's one or two babies in Ontario who die unexpectedly. Then it's shown on their autopsy they have critical congenital heart disease."
"If we look at babies that die without even getting a diagnosis, we're looking at one or two a year in Ontario, which is too many."
Dr. Jane Lougheed, head, cardiology, Children's Hospital of Eastern Ontario
Dr Jane Lougheed newborn heart screening
Dr Jane Lougheed uses a doll to demonstrate how oximetry testing works. Lougheed is the head of Paediatric Cardiology at CHEO . (Jean Delisle/CBC)

Newborn Screening Ontario was assured an additional $2.68-million in base and one-time funding for the provincial initiative of screening all newborns for congenital heart disease, in 2017. From 2018 forward, the total base budget for screening will be $14.25-million annually. All newborns in Ontario from January 2018 onward are to be screened at birth for both critical congenital heart disease and for hearing impairment.

At the present time in Ontario up to 30 percent of babies born with congenital heart disease are unidentified initially. Consequently, a small percentage of those babies die yearly, resulting from delayed treatment of their condition. As many as 450 babies each year in the province are born with critical congenital heart disease, many requiring life-saving surgical interventions and appropriate medications once they're diagnosed; usually shortly after or before birth.

The provincial government has targeted the situation for remediation, becoming the first province in Canada to specifically test each newborn baby with the use of an oxygen saturation monitor, for the existence of congenital heart disease. Irrespective of where the baby is born in the province; hospitals, birth centres, homes, the  swift, non-invasive test will be performed from 24 to 48 hours of birth, to ensure that those babies at risk will be immediately treated.


Two-year old Adeline Mahoney hands out toy hearts during a press conference announcing the new screening program. Mahoney was born with a congenital heart defect.
Two-year old Adeline Mahoney hands out toy hearts during a press conference announcing the new screening program. Mahoney was born with a congenital heart defect. (Jean Delisle/CBC)

Sandra Mahoney was given an early diagnosis while still pregnant, that her daughter Adeline had a complex heart defect. That knowledge allowed her to discover details about her baby's treatment, not in  he atmosphere of a sudden discovery and subsequent emergency situation, but while still stressful anticipating that her newborn's health would be complicated by her heart condition, yet allowing her the relief of knowing that the medical community was prepared to deal with it, to help normalize her baby's life.

Through blood testing, Ontario screens newborn babies for some 30 conditions. Member of Provincial Parliament, Attorney General Yasir Naqvi's five-year-old son Rafi was born with heart defects. "He got a lot of incredible care and this waiting room (at CHEO's cardiac clinic) is close to our hearts", he said at the hospital when the announcement was made. "I have spent quite a few hours in this waiting room along with my wife. I never thought I would be making an announcement in this room because I have always been there as a parent."

si-newborn-220-cp-rtr2tkob
The non-invasive screening is best done after 24 hours of birth. (Suzanne Plunkett/Reuters)

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Sunday, May 14, 2017

A Revision Whose Time Has Time

"There is an altruistic element to it, but I've honestly in my career never met someone who is willing to do that for free for a stranger."
"But there may be a sizeable number willing to do it if at least they're compensated for wages and some of their time."
Dr. Jeff Roberts, president, Canadian Fertility and Andrology Society

"It sounds like the [society] would like to open the door to a sort of fee-for-service system, where money is promised and people line up to sell their eggs or sperm or gestational capacity."
"People who find themselves in difficult financial circumstances will do this ... for the purpose of defraying their debt or paying for university tuition."
Juliet Guichon, professor, University of Calgary

"The fact they're being paid under the table makes them feel guilty, makes them feel part of something clandestine and hidden."
"They may not feel free to claim their rights and receive the health care they may need."
Vardit Ravitsky, professor, University of Montreal
An employee at a clinic prepares a sample of sperm and an egg for the process of fertilization under the microscope on May 25, 2016 in Barcelona.
An employee at a clinic prepares a sample of sperm and an egg for the process of fertilization under the microscope on May 25, 2016 in Barcelona. LUIS GENE/AFP/Getty Images

Canada enacted a law in 2004 allowing surrogates and donors of eggs and sperm reimbursement for expenses related to their cooperation with people anxious for parenthood acting as surrogates or egg or sperm donors. It is, however, illegal for anyone to directly charge for these services; they must be voluntarily given without recompense. A Royal Commission had studied the complex issues involved and extensive debate in Parliament concluded that Canadians remained opposed to the "commodification" of human sperm, eggs and wombs.

Now, the Canadian Fertility and Andrology Society is interested in spurring the federal government to overtime that ban of compensating people for their contribution to the parenthood of others. Their contention is that at the time the law was passed, this was an emerging technology, one that people were uncertain of, and insisted on precautionary measures  being put in place. Since that time, women in Canada have gone to great lengths inconveniencing themselves by charitably carrying someone else's baby to term.

These women can legitimately claim expenses related to their voluntary pregnancies, but they may not receive payment for that service. But although it remains a criminal act to pay a fee for the acquisition of eggs or sperm, fertility brokers and others in the system beak the rules with a measure of impunity. That being the case, since it is illegal, donors and surrogates have no real self-interested incentive to become involved -- other than those rare individuals who charitably offer themselves regardless.

Many Canadians who are anxious to become parents, but cannot themselves through natural means acknowledge the indefinite wait that is imposed upon them by the criminalization of the means. And many visit other countries to hasten the process where it is not illegal to acquire sperm and eggs, and to rent out a womb, as it were. Sherry Levitan, a member of the society's board suggests that maximum allowable payments could be set by the government, reasonable rates that are not outrageous.

She points out the unfairness of Canadians' disadvantage "in terms of managing their own fertility care". One bio0ethicist who has studied the situation extensively and is viewed as an expert is in support of permitting payments to be made; but her perspective is that it should be done in a manner that is seen to be fair to the donors, the surrogates and the children that result; not particularly for the purpose of benefiting the parents per se.

As Professor Ravitsky points out, the criminal ban has led those transactions to take place within the atmosphere of a grey market. She points out how unfair it is that women are expected to provide eggs or to become surrogates out of a sense of charity for others, while lawyers and brokers and owners of clinics profit from the situation. The Assisted Human Reproduction Act which makes it a crime to buy the services of surrogates or donors remains in effect for the time being, administered by Health Canada.

In agitating for change, the Canadian Fertility and Andrology Society, while standing to gain if it does proceed, has failed to address one additional issue. And that is, quite simply, when pregnancies ensue the universal health care system in the country picks up the medical costs. At the present time there are Canadian women offering, at no charge to foreign prospective parents, to lend themselves to the enterprise of surrogacy. Those foreign parents-to-be get quite a bargain. They pay the surrogate mother only her expenses related to the pregnancy in recognition that this is the law in Canada.

The surrogate mother uses the universal health care system to look after all the medical requirements involved. And this is a medical cost that the Canadian taxpayer picks up. There should be a provision distinctly addressing this situation; that should foreign parents-to-be use the services of a Canadian surrogate, they should be financially liable for the health services given that surrogate during the course of her pregnancy, and the baby's delivery.

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Saturday, May 13, 2017

The Bottom Line for Pharmaceuticals or the Top Line for Saving Lives?

"It is becoming increasingly difficult to disregard the costs of these new therapies -- side effect costs, costs to quality of life and financial costs ... especially when the benefits are very, very small."
"The vast majority ... are associated with extremely modest advances [in life-extension]."
Dr. Chris Booth, oncology professor researcher, Queen's University, Kingston, Ontario

"I just look back over the last fifteen years and [feel] we've really squandered a lot of resources pursuing meaningless targets."
Dr. Tito Fojo, oncology professor, Columbia University, New York, New York

"Lack of evidence doesn't mean there's lack of benefit, and sometimes with a patient you don't know until you've tried."
"There is nothing so powerful as seeing a patient who should be dead, who's had a complete remission."
Deb Maskens, kidney cancer patient, founder, CanCertainty, advocacy group
cancer cell
Cancer treatment has changed dramatically over the past several decades, and there have been some acclaimed success stories, with people recovering in greater numbers, and more people than ever 'beating' cancer, going on to live their lives. There is general agreement that some new cancer drugs have been transformative in the success of cancer treatment, but there is also an increasingly reluctant-to-admit but obvious failing in many others; the hype surrounding them is hopeful, but the reality belies the hype.

For all such drugs, those that have true merit and the others that promise while not delivering, the costs of their procurement and use is steep, so costly that they strain the ability of drug plans, governments, workplace insurance and patients to pay for them.Only three of 17 cancer drugs on the market since 2014 and 2015 rated well with evidence of "overall survival" with their use, after approval by Health Canada. Of four others of the 17, life was extended by 1.4 to six months. For the remainder no clear conclusion could be reached of their merit in use.

List prices for these drugs? Monthly, $4,700 to $33,000. In the early 1990s when Taxol was introduced and its effect was lauded against several types of advanced cancers, its popularity and huge cost attracted the attention of the pharmaceutical industry to the vast profits waiting to be made. Research and development to produce other successful, best-selling drugs went forward full-steam. Herceptin treatment for aggressive breast cancer; Gleevac to treat adult leukemia; BRAF-inhibitors to treat melanoma; and immunotherapy drugs with their promise in dealing with a variety of cancers, surfaced as true successes.

Dr. Maureen Trudeau, head of medical oncology at Sunnybrook Health Sciences Centre in Toronto cites Opdivo, a new treatment for melanoma, able to retain life for 30 percent more patients than had previous therapy: "It's incredible. Some of these drugs are changing lives", she notes. Those, granted, are the success stories; the list of drugs approved by Health Canada in the past two years appear to fall short of being wonder cures, despite the hype surrounding them, matching their sky-high costs.

The rising cost of cancer

The average monthly cost of newly approved cancer drugs (in 2013 U.S. $)

up to 19801981 - 19891990 - 19951996 - 20002001 - 20052006 - 20102011 - 2013$289$1,113$2,551$3,232$6,948$10,406$10,761
Source: Center for Health Policy & Outcomes, Memorial Sloan Kettering Cancer Center

Still, it is undeniable that people suffering from cancer survive longer now. The number of Canadians alive five years after their dread diagnoses has advanced to 63 percent, an increase from the 56 percent standard of the early 1990s and late 2000s. More screening, allowing cancers to be discovered at an earlier date, along with better treatments are what the Canadian Cancer Society attributes to the growing survival rates.

Preliminary results on new drug treatments are accepted as a quasi-guarantee on longer-life outcomes in recognition that actual survival improvements in short trails are difficult to measure. Health Canada, as well as U.S. and European regulars all accept this. The social pressure to permit what appear to be promising new cancer treatments to enter the market as quickly as possible without waiting to judge whether they may prolong people's lives gives priority to the former and a back seat to the latter.

From the perspective of patients, anxious to prolong their lives, improvements allowing a few months more life may permit a dying person to share their family a little longer, or even buy time during which a superior advance may be on the horizon in care and miracle drugs. Approval of new drugs is a costly affair; Opdivo, a major breakthrough for melanoma comes at a $8,200-per-month pricetag. Yet it was found to be no more effective than existing chemotherapy for lung-cancer patients, and that finding led Biristol-Myers' stock to plummet.

Novartis can produce evidence that it can cost a pharmaceutical company up to $2.6-billion to produce one single, new drug.  Blincyto, found to extend median survival for some late-stage adult leukemia patients by 3.7 months has a cost of $33,000 for 28 days' medication. Six months after its approval, an alert from Health Canada gave warning of mounting evidence it can trigger potentially fatal inflammation of the pancreas.

A high rate of death and lesser but serious side-effects in early stage patients for those using Zydelig which improved overall survival for advanced leukemia sufferers, spurred Health Canada to issue a warning. One analyst claimed the drug was "dead in the water". Its cost was relatively modest, at $4,700 a month. The simple fact is that most of the drugs have a long list of toxic side-effects attached to their use.
Steve Rudaniecki took part in a clinical trial at Hamilton’s Juravinski Cancer Centre. Almost immediately, the lumps and bumps from his chronic lymphocytic leukemia started to disappear.
Steve Rudaniecki took part in a clinical trial at Hamilton’s Juravinski Cancer Centre. Almost immediately, the lumps and bumps from his chronic lymphocytic leukemia started to disappear.  (John Rennison / The Hamilton Spectator)

Novartis charges $7,000 monthly for the drug Afinitor. And that cost is static, irrespective of whether the dose reflects the recommended 10 milligrams, or is reduced to 5 mg or even 2.5 mg. "It is reprehensible in my mind", Sunnybrook oncologist Dr. Maureen Trudeau noted. Little wonder with these sky-high prices, new cancer drugs are placing stress on public and private health plan funders. An estimated 1,800 cancer drugs are in the development stages.

And then there is the fact that a growing number of these new drugs are taken as oral pills or injectables that patients are able themselves to administer in their homes Which translates to the expectation that those people become responsible for the cost of the treatment themselves, while treatment that takes place in hospitals is covered under medicare.  In the United States, many payers remain willing to pay such exorbitant prices; a fact most encouraging to the pharmaceutical manufacturers.

cancer drug costs

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