Dec 1996

The Women's Group Newsletter

• Open Season on Health Insurance
• A new Twist on the PAP Smear
• Breast Cancer Screening

Open Season on Health Insurance

Dear Ladies,

First comes bow hunting season, then black powder, then open season on your health insurance. Better wear safety orange and beware!

Last January was especially difficult for patients and our office staff alike, and the trend toward more and more HMO promises lead to more frustration at the time when health insurance plans switch.

The basic problem, we believe, is that most of us get our insurance through our   employers. On the other hand, if each of us shopped for a plan, you’d better believe
we’d know the policies and rules of our plans and hold onto that insurance manual like the operations manual of some critical piece of equipment.

If your insurance through your work is changing, your should be given a booklet
detailing their rules. Read it! If you’re going from traditional insurance to an HMO, know that visits to anyone including an emergency visit other than your "primary care provider" (i.e. designated Family physician or Internist) will need to be authorized by that doctor.

Know that any procedure or test will also have to be authorized. Assume this unless you can find, in writing, information to the contrary.

HMOs and PPOs have in-network and out-of-network hospitals, pharmacies, x-ray
facilities, physical therapists, mental health professionals, and doctors.
Those on Medicare and Medicaid who have signed up for an HMO must abide by the HMO’s rules or be responsible for payment for services.

No one likes reading legalese in insurance books, but the book is your contract with
your insurer. Read it or beware.

A New Twist on the Pap Smear

by Dr. Lois McLauchlan

There are some new developments on reading the Pap smear you may have heard
about. They are PAPNET, AutoPap, and ThinPrep.

First, some background. There has been an incredible decrease in cervical cancer in
the last 30 years. This has largely been due to regular screening by Pap smears. Even so, it is likely that some precancerous cells are missed by the Pap, and occasionally some Paps are read as abnormal when there is not a real problem.

There may be more than one reason for a problem to be missed. Perhaps the
suspicious cells never were sampled, or if sampled did not get onto the slide to be
checked. Some experts feel these two reasons may account for over two thirds of this type of "false negative" error. Possibly abnormal cells were overlooked or not recognized by the cytotechnologist (person trained to read Pap smears). Rarely, the specimen is lost or mixed up with someone else’s accidentally.

The PAPNET system addresses the chance that some possibly abnormal cells were
not picked up by the lab by using a computer programmed with artificial intelligence to rescreen your slide. Currently, labs rescreen 10% of "negative" (normal) slides, and may do this either manually or automatically. The FDA has approved PAPNET only as such a quality control measure, however, the company is marketing this product directly to the public. It would seem they would like you to assume that this is the superior way to avoid a "false negative" reading, because if you want to be sure that your PAP is rescreened in this particular way, you need to order it and be prepared to pay for it (about $40.).

AutoPap is similar to PAPNET, but is also programmed to determine a normal Pap
reading (i.e. is capable of bypassing people altogether for the initial reading of the Pap).

ThinPrep is a technique that allows not only more of the cells in the sample to be viewed for interpretation, but displays them more clearly for analysis. This may decrease what many feel is the largest pitfall for error, but is not yet generally available.

At present, existing methods have improved Pap smear screening accuracy and
cervical cancer prevention tremendously. Consider that even if there is as high as a
20% false negative rate, getting three annual Pap smears would reduce this to under 1% as the chance of missing a problem two or three times gets to be quite low. The current system indeed works well as long as people use it!

Breast Cancer Screening

By Dr. Nancy Rudd-McCoy

We do not know what causes breast cancer, so we resort to early detection of this disease. The goal of breast self exam is to, over time, become familiar with where one’s lumps are, so that any change will be caught. Of course, breasts change throughout the menstrual cycle, so the exam should be done right after one’s period.

In regards to mammography, they have greatly reduced the number of surgical biopsies by setting up a hierarchy of testing. If the first level, the mammogram, is not highly reassuring, one proceeds to magnification views or ultrasounds. If one or both of these is not highly reassuring, one proceeds to core (large needle) biopsy under ultrasound or mammographic visualization.

Thus, our local radiologists have reduced the rate of missed cancers and open biopsies very much.

A couple summers ago, there was much media play about two Canadian studies that showed that mammograms in women younger than 50 did not enhance survival. Note that the US investigators dropped out of these studies because of the poor quality of the films obtained on outdated Canadian equipment. What was also not said was that 51 is the average age of menopause, and that cancer before that age tends to be faster growing. One could therefore make a case for doing mammograms more frequently in younger women.

Nevertheless, the guidelines that most insurance companies acknowledge are:

· baseline mammogram between age 35 and 40
· mammogram every     other year until 50
· annual mammograms age 50 and above 

More frequent or earlier studies are valid in a woman whose mother, sister, or daughter had breast cancer; who had breast cancer herself; or whose biopsy showed atypia.

We have a breast self exam model in the office we encourage you to take time to use.

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