Category: News

Well-being survey reveals racial divide

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The region’s top score is driven in large part by the high education and income levels of whites and Asian Americans living in the Maryland and Virginia suburbs, the report says. Although some of the information underscores what is generally known about the area, the report by the American Human Development Project, an initiative of the Brooklyn-based nonprofit Social Science Research Council, reveals some startling gaps in what it calls the building blocks of a good life.

White D.C. residents have the longest life expectancy of whites in any state, 83.1 years, the report says. That is 12 years longer than the life span, on average, for blacks in the city. The average life expectancy for blacks is 71, the lowest for blacks in any state. The average life expectancy for blacks in the District is about the same as what it was for the average American in the 1970s.

The index of well-being does not vary greatly among the top 10 metropolitan areas, said Sarah Burd-Sharps, a co-author of the report. The Washington region ranked first, followed by the Boston, New York, Philadelphia, Chicago, Los Angeles, Atlanta, Miami, Dallas-Fort Worth, and Houston areas.

In many cases, however, “there are enormous chasms when you pull the data apart,” she said.

Those extremes are evident in the D.C. area. The District has the highest infant mortality rate in the nation. And although the District has a high drop-out rate and low school enrollment for ages 3 to 24, “it’s also a place that attracts people with high levels of education to high-paying jobs,” she said.

“What pulls it way up in scale is the number of people who have a bachelor’s degree or a professional degree,” she said.

Nearly half of the people in the Washington region – about 47 percent – have at least a bachelor’s degree, compared with 41 percent in the No. 2-Boston region, according to the report.

The report tracked health, education and income in each state and the District, each of the 435 congressional districts, and each of the five major ethnic groups in every state, Burd-Sharps said.

“If you want to know whether we’re making progress, you need to measure these things . . . which are as critical to stock market gyrations and all the money measures which we measure with great intensity,” she said.

The authors ranked the congressional districts because they are linked to elected officials. “Their job is to make sure people are not dying premature deaths at huge rates,” she said.

Three of the region’s congressional districts – the 11th and 8th in affluent Northern Virginia and the 8th in Maryland, which includes high-income parts of Montgomery County – were among the top 10 districts in the United States, the report says.

With a median household income of ,000, according to the latest census data, and an unemployment rate well below the national average, the Washington region is considered the most affluent in the country.

The report used an index that is a composite measure of three equally weighted indicators: median personal earnings, life expectancy, and school enrollment of those ages 3 to 24 and highest degree attained by adults 25 and older.

The authors used 2008 census data for education and earnings and calculated life expectancy using data from the U.S. Centers for Disease Control and Prevention.

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Wash Post Health

New, more graphic cigarette warnings unveiled

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Federal health officials Wednesday unveiled plans to replace the warnings cigarette packs began carrying 25 years ago with new versions using images that could include emaciated cancer patients, diseased organs and corpses.

Public health authorities and anti-smoking advocates hailed the move as a milestone in the battle against tobacco in the United States that began in 1964 when the surgeon general first declared cigarettes a public health threat. That battle made steady progress for decades, but has been stymied in recent years, with a stubborn one in five of adults and teens still smoking.

Tobacco remains the leading cause of premature and preventable death in the country, causing 443,000 deaths each year and about one-third of all cancer deaths.

Armed with new powers approved by Congress last year, the Food and Drug Administration is proposing warnings that include one containing an image of a man smoking through a tracheotomy hole in his throat; another depicting a body with a large scar running down the chest; and another showing a man who appears to be suffering a heart attack. Others have images of a corpse in a coffin and one with a toe tag in a morgue, diseased lungs and mouths and a mother blowing smoke into a baby’s face.

The new warnings will cover half the front and back of each pack and 20 percent of each large ad.

The FDA will gather public comment on 36 proposed images until Jan. 9 and select nine by June 22 after reviewing the scientific literature, the public comments and a study involving 18,000 people. Beginning Oct. 22, 2012, any cigarette makers that do not put the new warnings on their packaging will not be allowed to sell their brands in the United States.

“When the rule takes effect, the health consequences of smoking will be obvious every time someone picks up a pack of cigarettes,” FDA Commissioner Margaret A. Hamburg said.

The move was praised by public health and anti-tobacco advocates, although some said they wished the warnings included other elements, such as a toll-free number to call to help people quit and messages about the benefits of quitting.

“In implementing the new warnings, the United States is catching up to scientific best practices,” said Matthew Myers of the Campaign for Tobacco-Free Kids.

Others, however, criticized federal officials for not going further, such as by banning smoking in more places.

“Pictures on cigarette packs is a totally inadequate federal response,” said John F. Banzhaf III, a professor of public health law at George Washington University who runs the activist group Action on Smoking and Health.

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Wash Post Health

Doctor opening new late-term abortion clinics in D.C. area, Iowa

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A Nebraska doctor who is one of the few in the country to perform abortions late in a pregnancy said Wednesday that he would open new clinics in Iowa and the Washington area.





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Wash Post Health

Trying out game meat

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I also eat fish, which though not lean contains healthful fats. I’d love to add more meats to that rotation, however. And there’s a whole class of food I hadn’t considered: game.

Game gets kind of a bad rap. Some people object to the idea of hunting deer, rabbits, waterfowl or other game creatures. Others hate the “gamey” taste. But the locavore movement, paired with a poor economy, has led some folks to embrace hunting as a way of procuring local, healthful and inexpensive meat. And if hunting’s not for you, you can always buy farm-raised game at a store or order it from afar.

If you’re new to the game game, here are some facts that might interest you:

It’s more lean. Game animals, even those raised on ranches, usually get more exercise than farmed domestic animals. That makes their meat leaner, lower in total fat and saturated fat and in calories, compared with much domestic meat. However, most game has about the same amount of cholesterol as domestic meat (though bison, poultry and wild fowl have less, and venison has more), says Melina Jampolis, a San Francisco-based physician and nutritionist. Increased muscle activity also makes game meat darker; older animals’ meat is generally darker than younger animals’, too, and it tastes a bit stronger.

Venison is especially lean. The fat in venison is stored right under the skin, not marbled into the muscle (which is the meat we eat). Because the fat doesn’t taste very good, hunters and butchers usually remove as much of it as they can, says West Virginia hunting instructor Jackson Landers. That makes the already lean meat even leaner. Cooking methods such as marinating and braising aim to boost flavor (which fat imparts to other meats such as beef steaks) and break down muscle fiber so the meat’s moist and tender.

It has key vitamins and nutrients. Because hunted game animals and some farmed game have a more varied diet (often grass-based) than typical farm animals such as cows, they usually have more omega-3 fatty acids, which have anti-inflammatory benefits. However, fatty fish such as salmon are better sources of omega-3 fatty acids than game meat is, Jampolis says. Venison and some other game meats are also rich in iron and B vitamins.

It’s drug-free. Hunted game is free of added hormones and antibiotics. Hormones aren’t used in farm-raised game, but the animals may be given antibiotics. Before the creatures are slaughtered, they have to have been off the antibiotic for at least five days to make sure there’s no residual medicine in the meat on your plate.

Some is organic, some isn’t. Hunted game is organic, but there’s no way to officially label it as such. On the other hand, farmed game can be called organic if it’s raised under conditions outlined by the Department of Agriculture. Look for the USDA’s “organic” label, which some organic meats carry.

It can be red or white. The USDA considers game birds white meat, though their breast meat is darker than that of domestic chicken and turkey. That’s because, unlike those farmed birds, game birds fly. The breast muscles need extra oxygen to do that work, and that oxygen is delivered by red blood cells. The USDA categorizes game mammals as red meat. A protein called myoglobin holds oxygen in the animals’ muscles and makes their meat darker in color.

Safe cooking is crucial. Cooking game meat requires the same care as cooking any other meat. Home cooks should use separate knives and cutting boards for meat and clean those tools before and after using them to cut game. Meat should be kept cold (below 40 degrees) and cooked until its internal temperature is at least 160 degrees. Much game benefits from long cooking, which promotes tenderness. For more on safe handling, see a guide on the Food Safety and Inspection Service’s Web site ( www.fsis.usda.gov , search “Game From Farm to Table”). Cooked game meat can remain pink even after it has reached that safe temperature, according to the agency, which is part of the USDA.

It can be really cheap. Nick Chaset, a graduate student at Georgetown University and founder of the Bull Moose Hunting Society (with a fledgling chapter in the District), says he can get 50 to 70 pounds of meat from a deer he hunts; calculating the cost of licenses, equipment and butchering, he says that meat ends up costing .25 to .50 a pound. Compare that with grass-fed, organic beef, he suggests, which can cost a pound or more. However, it’s illegal to sell meat you’ve hunted, so if you want to realize this cost savings, you’ll have to take up hunting or make friends with a hunter.

It can be really expensive. Store-bought packages can cost upwards – sometimes way upwards – of a pound. You can find fresh or frozen varieties in grocery stores; bison, in particular, has become a popular low-fat choice in the meat case.

Click on the map to see where to find and eat game meats in DC, MD, and VA:

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Painful lymphedema afflicts millions of patients after cancer surgery

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Lymphedema, a painful and chronic swelling of the lymph nodes, may affect up to 70 percent of women who have undergone surgery or received radiation for breast cancer. Men who have undergone prostate cancer surgery often experience it as well. Yet the condition, estimated to afflict 3 million to 5 million Americans, is rarely discussed by doctors; it is sometimes ignored and frequently misdiagnosed, and it routinely goes untreated.

“My surgeon said he’d never had anybody ever develop it. . . . He still says that. It is just really hard for doctors to recognize it, for some radiation oncologists to admit” that it happens,” Pike says.

Lymphedema is the accumulation of fluid at or near the site of cancer surgery – in the groin, the hands, the arms, the legs or the chest – as result of a blockage in the lymphatic system. That’s the network of vessels running the length of the body through which lymphatic fluid travels to protect the body against invaders.

Scarring from surgery or radiation can cause such a blockage and the consequent buildup of fluid. This results in swelling, which in early stages can feel like nothing more than a slightly distracting tingling. Over time, however, the swelling can get worse, becoming painful, chronic and debilitating: restricting movement, impeding daily activities and requiring constant care. And once lymphedema appears, it can be hard to get rid of.

Says Judy Nudelman, a family physician at Brown University who is also a chronic lymphedema sufferer, “It affects everything I do,” from playing tennis and getting dressed in the morning to flying in airplanes and even just sitting in the sun. “It’s like everything I would do without thinking has to be thought through again,” says Nudelman, whose lymphedema began after breast surgery.

People with lymphedema, according to a study last year in the journal Family Relations, tend to drop out of many activities, “either modifying the way they participated or not taking part.”

Cancer surgery does not always lead to lymphedema, and there can be other causes of the painful condition. But there is strong evidence of cause and effect when cancer surgery is performed, because it often involves a surgical examination of nearby lymph nodes to determine whether the cancer has spread there as well. It does not really matter what kind of cancer is involved – whether it’s prostate, melanoma, ovarian or something else – for there to be a risk of lymphedema, though most research has focused on its association with breast cancer.

Feeling abandoned

Yet as painful and common as lymphedema can be, it still gets very little attention in the medical literature, and, according to increasingly vocal patient groups, it is infrequently mentioned by doctors when discussing an upcoming cancer surgery or radiation treatment.

A Stanford University survey several years ago found that, on average, the lymphatic system gets only 15 minutes of attention during four years of instruction in medical school, and lymphedema may get no mention at all.

For Nudelman, who set out to raise awareness after her own problems began, one benchmark for this lack of interest is how often she hears that, as in her own case, lymphedema is “not even in the consent form” patients sign before surgery or radiation.

As a result, people who develop lymphedema after treatment often have a difficult time finding help for it. Pike, for instance, ended up going from one doctor to another after her a bilateral mastectomy resulted in lymphedema in both arms and her chest, and tried therapies that made things worse.

Along the way, she says, she also encountered medical practitioners who seemed to think she was just whining. Their attitude was, “I saved your life, now get on with it,” she recalls. Pike says she was not surprised to read a study that said that women with lymphedema suffer not just from disability and disfigurement but also “from a feeling of abandonment by the medical community.”

Pike uses massage and wears special garments 24 hours a day to deal with her condition.

Varying criteria

Nudelman says the frustration for many patients is that hospitals and doctors often tell them “we have zero incidence of lymphedema cases in our institution.” Having treated some of those women, she says, she knows those claims don’t hold up. But no hospital or individual surgeon wants a reputation for doing procedures that regularly result in complications, which is how they may view lymphedema.

Some of the problems may lie in the inconsistencies in the criteria used to identify lymphedema; this lack of standardization can mean that not all people experiencing most of the symptoms are recognized as having the condition. As a result, some estimates for lymphedema in women who have undergone breast cancer are as high as 70 percent, while others, using narrower criteria, put it as low as 6 percent.

Why such a wide variance? It mostly depends on how soon after surgery the studies focus on the symptoms, and on what body parts are examined. Immediately after surgery, the number of women showing symptoms is likely to be lower than later on because it takes time for the fluid to accumulate and begin to cause damage. At five years out, according to a 2008 study in the Journal of Clinical Oncology, 42 percent of women surveyed had reported symptoms.

Pike, whose battle with lymphedema pushed her to become an advocate, points out that patients are vulnerable “at any point after cancer treatment.” “As more people survive,” she says, “the more lymphedema we’re obviously going to see, because the risk increases as time goes on.”

Mishori is is a family physician and faculty member in the Department of Family Medicine at Georgetown University School of Medicine.

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Wash Post Health

Vets with PTSD train dogs to help comrades

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Yount was then working as a social worker, and on that particular morning he had to take a young boy from his mother’s house and drive him to new foster parents. The boy cried and cried. But halfway through the trip, the car suddenly grew quiet. “I looked in the back seat,” said Yount, “and the puppy’s head was lying on the boy’s lap.”

That demonstration of canine comforting in 1995 sparked the idea for a program that is getting underway at a Veterans Affairs hospital in California and at Walter Reed Army Medical Center. It’s called Paws for Purple Hearts, and it is helping injured veterans and active-duty troops in two very different ways.

The program trains Labradors and golden retrievers – including many offspring of Yount’s dog Gabe – as lifelong service dogs and companions for veterans who use wheelchairs. But for their first two years of life, these dogs spread their love around in another way. They are trained by veterans suffering from post-traumatic stress disorder. For many of these psychologically damaged warriors, this human-canine connection provides them with emotional sustenance, a mission and important lessons in patience that help them get on with their lives.

“It was challenging, and it tested my patience, but it taught me to have patience again, and that was something I had really lost because of PTSD,” said former Army reconnaisance officer Amanda Heidenreiter, 26, of Columbia, of her experience training Owen, a golden retriever. She had returned from Iraq terrified of crowds and children, and “Owen helped me relax, calm my anger.”

Therapy and more

Service dogs have been provided to disabled veterans in the United States since World War I, and programs that train “therapy dogs” for people with psychiatric disorders have grown steadily in recent decades. The Paws for Purple Hearts program, which began two years ago, has drawn the interest of a cluster of scientists who think that the human-dog relationship may have measurable clinical impact on the health and well-being of patients, including veterans with PTSD.

Sue Carter, a psychiatrist at the University of Illinois, says her interest in the human-animal bond developed out of her research on oxytocin, a mood-influencing peptide that flows through the bloodstreams of mothers and newborns after birth, aiding in breast-feeding and mother-child bonding. Carter and others believe it probably plays a role in human-pet interactions as well.

Other scientists, such as Jozsef Topal at Loran Eotvos University in Hungary, are studying dog behavior to understand how human brains work, particularly when it comes to social intelligence.

Through thousands of years of dog domestication, humans have created animals that are particularly attuned to human emotions and cues, Topal has written. Although human DNA is closer to that of chimpanzees, dogs are closer to us in their ability to fathom the intentions of others, especially humans. In other words, through our breeding of dogs, humans have selected for dog genes that might provide insights into the genetic components of our own behavior.

For this reason, according to Topal, dogs could be useful for studying disorders such as autism and schizophrenia. Dogs such as Gabe, which seem to have a genetic disposition to extreme empathy, might provide information to help us understand people better. If we could discover the molecular basis for Gabe’s behavior, it might point to factors in our own genetic background that enhance characteristics such as empathy.

Genomes aside, “you don’t have to be a brain scientist to know that these dogs help vets,” said William Smith, 55, a wheelchair-using veteran who lives in Modesto, Calif. His dog Venuto is Gabe’s grandson. “It’s so obvious, it’s simple.”

A change of attitude

Smith, who was injured while on active duty in 1983, credits Venuto with helping him sleep better without the help of two drugs, and with becoming more laid-back. “When you get out of the service, you treat your family and your friends like it was in the military: You’re rigid, and everything is ‘boom, boom, boom.’ It’s not a good way to be. [Venuto] has helped me develop more of an attitude of “que sera, sera.”

Retired Staff Sgt. Christopher Hill, a 20-year Marine veteran, returned from Iraq in 2004 an angry, hurting man. A rocket attack had slammed him into a concrete barrier and killed three of his comrades, including one who was on the phone with his father when the round hit. One minute he was discussing plans for his arrival home, the next minute his body lay in pieces.

Six men with whom Hill served have committed suicide since coming home, an emotional catastrophe that Hill attributes to the veterans’ inability to reengage with a society that doesn’t share their experiences of violence, loss, terror and numbness.

“You’re there so long, then you get on a plane and come home, and you don’t care about yourself or anyone,” says Hill, who is 42. “You’re introduced to people, shaking hands, welcoming you home. You don’t care. You’re deep within your own stuff. It’s like camouflage.”

By the time Hill was admitted to the VA hospital in Menlo Park, Calif., for treatment of spinal cord and brain injuries and PTSD in 2009, he was going 72 hours without sleep, followed by 24-hour crashes.

At the first group therapy session Hill attended at the hospital, he saw that “most of the guys were staring straight ahead. But the ones with the dogs looked peppy. I said, ‘I gotta get one of them.’ ”

Only a few months earlier, Yount, who has not served in the military, had started bringing dogs to the hospital to have inpatient vets train them for comrades who relied on wheelchairs. Paws for Purple Hearts was just beginning, and Hill was one of the first to get a dog.

“It was hard at first to learn how to talk to him, but he has revamped my lifestyle,” said Hill as he stroked Verde while walking around the grounds of the hospital during a recent visit.

Hill, who was a music producer before joining the Marines, is a quick-talking, funny man, but he says the violence and stress had clammed him up. “All the drugs . . . made me into a zombie. But now, I have to be up at 7 to feed him. Verde doesn’t want anything from me except to be there with him. He’s just like the guy in the foxhole. So for that, I’m willing to talk and act like [bouncy TV aerobics instructor] Richard Simmons.”

After training Verde, Hill said an emotional goodbye when the dog was sent to a wheelchair-using vet. But Verde proved too skittish to be a guide dog, and a year later he was reunited with Hill for good.

Now that Paws for Purple Hearts has been underway for a while, Yount says he can clearly see how training dogs helps vets open up to communicating with their peers and therapists. The dogs just have a way of getting through to people who shun human touch. “If you went up to someone and offered your hand and they rejected you, would you do it again? No,” he said. “But these retrievers are bred to be as engaging as possible. They are the perfect beings for this kind of job.”

The mission continues

The vets who train the dogs spend several months with them, sometimes longer, and letting go can be difficult. Yount said that some experience sleep problems after their dogs go, but “processing that sense of loss in saying goodbye to their dog has been a valuable gateway to processing other loss issues that have been hampering their recovery. ”

And it’s terribly important for veterans to feel they are continuing a mission that held them together through the violence and stress of war. “PTSD carries a stigma, that you’re broken and wounded,” said Yount, “And many guys have guilt for not still being in the fight. The idea of Paws for Purple Hearts is you can be part of the war effort while you’re getting treatment.”

Officials at Walter Reed did not allow me to visit the installation or speak with active-duty soldiers in the Paws program there, but at the Menlo Park hospital, I watched Yount – a hulking, crew-cut western Pennsylvanian transplanted to California – show a veteran how to control his chocolate Labrador with gentle commands and rewards of doggie treats.

This is where the dual benefits of the program are apparent. The vets are working on behalf of a wheelchair-using vet, but are learning – or relearning – the emotional skills needed to manage a dog that will help them function in a world of normal human feelings and interactions.

“The training of a dog requires you to emote,” Yount says. “That’s hard for a guy with PTSD who’s emotionally numb. But if you tell them it’s necessary to train this dog to help a fellow vet, there’s motivation. First, they have to sound happy. It’s fake. But there’s a concept that says, ‘Fake it until you make it.’ Within a few days, it sounds more and more sincere. Pretending to sound happy actually impacts your feeling of happiness.”

Heidenreiter, the former reconnaisance officer, said training a golden retriever named Owen forced her to go into malls, restaurants and stores so that the dog would be a good companion for a physically disabled veteran. Doing so terrified her at first, but eventually she learned to relax.

‘A natural remedy’

As many as a dozen service members may be involved in training dogs as they move through their own rehab. So far nearly 200 vets and active-duty service members have participated. Only three Paws for Purple Hearts dogs have been placed with disabled vets. But Yount says more are in the pipeline, and even the “failures” provide important companionship to vets such as Hill.

Yount is hoping to expand the program, which is run out of the Bergen University of Canine Studies of Santa Rosa, Calif., but it has faced some obstacles. Thus far it has operated with charitable donations, including a major one from Finmeccanica North America, a defense contractor.

Federal money has been held up by bureaucratic problems as well as the Catch-22 of evidence-based medicine: There are few data yet to show that Yount’s program has positive effects; but to get the data, you need to expand the program.

Still, the effort seems to be gaining momentum. Legislation that would create a million, five-year pilot program at up to five Veterans Affairs facilities is currently before the Senate. In October, Paws was cleared to set up shop at the new National Intrepid Center of Excellence, a research, diagnosis and treatment center in Bethesda for service members and vets with traumatic brain injuries and psychological problems.

Carter, the University of Illinois psychiatrist, says dog therapy for wounded warriors makes sense. “The pet is an evolved, natural remedy,” she said. “The dog became an extra pair of ears and legs to protect us. The boy warrior with his spear may have had a dog with him for an awful long time in history. Thousands, tens of thousands of years.”

Allen is a freelance science writer in Washington and author of “Vaccine: The Controversial Story of Medicine’s Greatest Lifesaver.”

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Workers’ health insurance costs for 2011 include higher premiums and co-payments

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The selection is likely to be even less appealing this year than last. According to experts and industry insiders, recent trends suggest rates will continue to rise and employers will continue to shift more of the cost of health insurance onto workers – asking them to shoulder a larger share of premiums, for instance, or increasing out-of-pocket costs such as deductibles and co-pays.

This past year, overall premiums for employer-sponsored coverage – meaning the amounts paid by employer and employee combined – rose a relatively modest average of 3 percent for family coverage, according to a study by the Kaiser Family Foundation and the Health Research & Educational Trust. But the share of such premiums covered by the worker increased from 27 percent to 30 percent, with the result that the amount paid by workers rose an average of 13.7 percent.

The most comprehensive statistics on plan offerings for 2011 won’t be available for months. But a September survey of employers by Mercer, a leading benefits consulting company, suggests last year’s patterns will continue.

Overall, the employers said that they expected their health-care costs to increase between 9 and 12 percent – but that they planned to use cost-saving measures to effectively bring that increase down to 6 percent. Some 57 percent said one way they would do this would be to have their employees pay a greater share of the cost of coverage.

Many employers also said they would try to lower their costs by prompting employees to improve their health: Forty-four percent said they will add health management or wellness programs. An additional 38 percent said they will add incentives for employees to participate in existing programs.

Tracy Watts, a partner at Mercer, said this often involves lowering employee premiums or giving them gift cards for participating in health assessment surveys. These reviews alert workers to steps they could take to improve their health.

“There may even be incentives to achieve your ideal biometrics – blood pressure and body mass index, for instance,” she said. “That’s very encouraging, because it suggests that employers believe that focusing on members’ health is a good thing to do.”

Impact of the new law

Because this is the first major open-enrollment period since key provisions of the new health-care law started taking effect, many workers will wonder how much of the plan changes they see is due to the legislation. Not much, say analysts.

The law’s most market-altering changes – including provisions that may or may not control premiums – don’t kick in until 2014.

“We’re three years away from that,” said economist Paul Fronstin of the nonprofit Employee Benefits Research Institute. “For the most part, the plans don’t know what they’re going to be doing [in response]. It’s just too soon.”

There is a notable exception: On their next annual renewal date, all plans will be required to comply with certain mandates such as eliminating lifetime dollar limits on benefits and allowing parents to put adult children up to age 26 on their plan. Insurers that make certain changes to existing plans or employers that switch insurance carriers will have to offer additional benefits such as free preventive services.

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Review of prostate cancer drug Provenge renews medical cost-benefit debate

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The Centers for Medicare & Medicaid Services, which dictate what treatments the massive federal health-insurance program for the elderly will cover, is running a “national coverage analysis” of Provenge, the first vaccine approved for treating any cancer. The treatment costs ,000 a patient and has been shown to extend patients’ lives by about four months.

Although Medicare is not supposed to take cost into consideration when making such rulings, the decision to launch a formal examination has raised concerns among cancer experts, drug companies, lawmakers, prostate cancer patients and advocacy groups.

Provenge, which was approved for advanced prostate cancer in April, is the latest in a series of new high-priced cancer treatments that appear to eke out only a few more months of life, prompting alarm about their cost.

“This absolutely is the opening salvo in the drive to save money in the health-care system,” said Skip Lockwood, who heads Zero – the Project to End Prostate Cancer, a Washington-based lobbying group. “If the cost wasn’t a consideration, this wouldn’t even be under discussion.”

Those concerns have been heightened because the review comes after the bitter health-care reform debate, which was marked by accusations about rationing and “death panels.” The appointment of Donald M. Berwick to head Medicare only intensified anxieties. President Obama sidestepped a Senate battle by naming Berwick, who has advocated for scrutinizing costs, when Congress was in recess in July.

Because men tend to be elderly when they get diagnoses of advanced prostate cancer, Medicare’s decision will have a major effect on Provenge’s availability. Regional Medicare providers paying for Provenge would have to stop. Private insurers also tend to follow Medicare’s lead.

Medicare officials, who are convening a panel of outside advisers to vet the issue at a public hearing Nov. 17, say Provenge’s price tag isn’t an issue. But Berwick and other officials declined to discuss the rationale for the review.

“Certainly no one in the Medicare program would publicly state that the price tag would have anything to do with Medicare looking at it. But they are human beings, too. They notice things like that,” said Sean Tunis, director of the Center for Medical Technology Policy and a former chief medical officer at Medicare. Tunis said, though, that other factors, such as the special nature of the therapy and lingering questions about its effectiveness, were probably playing a more crucial role.

The review comes as the Food and Drug Administration considers withdrawing an approval for another expensive cancer treatment- Avastin for metastatic breast cancer – which triggered a similar debate even though the FDA too is not supposed to factor costs into its analyses.

Medicare usually covers new cancer drugs once they have been approved by the FDA. The decision in June to scrutinize Provenge prompted several members of Congress to question the action. Supporters have inundated the agency with hundreds of thousands of comments.

“I don’t want to blame Obamacare, but it just kind of figures that people are taking a look at what the cost-benefit ratios are and all that sort of stuff,” said David Dykes, 69, of Lorton, a retired federal employee who was hoping to try Provenge. “That may sound pretty good to the people who want to cut costs, but it doesn’t sound too good to me. This is something that could extend my life. I’d like to give that a shot.”

Some fear the move will discourage pharmaceutical companies from developing new cancer drugs.

“It is extremely chilling if, after spending a huge sum of money, time and effort to get a drug through FDA approval, you’ll then have to go through it all again to see if CMS will pay for it,” said Allen S. Lichter, head of the American Society of Clinical Oncology. “Firing a shot across the bow like this is not the way to have an intelligent and meaningful discussion about how we start to address the complex issue of drug costs.”

Provenge has long been the center of controversy. The FDA delayed Provenge’s approval in 2007. The rejection triggered outrage among patients, advocates and investors in Dendreon, the Seattle company that developed Provenge. The campaign to win Provenge’s approval included anonymous death threats, accusations of conflicts of interest, protests, congressional lobbying and vitriolic Internet postings.

Prostate cancer strikes 192,000 men in the United States each year and kills about 27,000. The only therapies are surgery, radiation, hormones and the chemotherapy drug Taxotere.

Unlike standard vaccines, which are given before someone gets sick to stimulate their immune system to fight off infections, Provenge is a “therapeutic vaccine,” designed to attack cancer cells in the body.

To produce Provenge, doctors remove immune system cells from patients, expose the cells in the laboratory to a protein found on most prostate cancer cells and an immune system stimulator, and infuse the cells back into the patient in a month-long series of three treatments. In a study involving 512 patients with advanced prostate cancer, Provenge increased median survival from 21.7 months to 25.8 months.

“To charge ,000 for four months, which comes out to 0,00 for a year of life, I think that’s too expensive,” said Toto Fojo of the National Cancer Institute. “A lot of people will say, ‘It’s my 0,000, and it’s my four months.’ Absolutely: A day is worth million to some people. Unfortunately, we can’t afford it as a society.”

Others agreed, especially given the modest benefit.

“I’d like to think cost doesn’t need to come up when it’s a slam dunk,” said H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice. “But when it’s a close call like this, it certainly has to be a factor. That’s 0,000 Medicare can’t spend elsewhere.”

But such commentary has caused widespread alarm among patients and advocates.

“The men most impacted by prostate cancer are African American men. If CMS doesn’t approve this, then this treatment becomes an exclusive kind of treatment for men who can afford it out of pocket,” said Thomas Farrington, president of the Prostate Health Education Network.

Others stressed that many men live far longer on the treatment and that even four months is extremely valuable to some.

“Whenever you are faced with a disease where you can lose your life, you really would like to extend it as much as you can,” said Leibel B. Harelik, 61, a prostate cancer patient who is executive director of the Prostate Cancer Resource Center in Austin.

Company officials say the cost is not out of line with that of other cancer drugs. Each treatment with Provenge, which the company estimates cost nearly billion to develop, is tailored to each patient.

“Because of that, we have higher costs associated with this product,” said Mitchell H. Gold, Dendreon’s chief executive. “Provenge is a unique new medicine that prolongs the lives of patients with late-stage prostate cancer. These patients need access to innovative new medicines.”

Whatever the outcome on Provenge, many on both sides agreed that more debate over other new high-tech therapies was likely to come.

“At some point, if we keep paying these very high prices for treatments that provide very limited benefit, we’re going to reach the point where we can no longer afford health care,” said Alan Garber, a professor of medicine and economist at Stanford University. “Some say we’re living through that right now.”

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No clear path for GOP on health care repeal

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And that might not be a bad thing if you’re a GOP strategist. It keeps the issue Senate Republican leader Mitch McConnell calls the “tipping point” in the midterm elections alive for 2012, when they’ll try to unseat Obama himself.

Republicans will control the House in January, but they don’t have the votes to overcome a Senate filibuster, much less Obama’s veto on repeal. Plan B, denying funds to carry out the law, could backfire if it escalates to a government shutdown.

Other options call for legislative guerrilla tactics.

Republicans could use the oversight authority of Congress to slow down or block regulations, essentially tying up the instruction manual for the overhaul. Expect flyspeck scrutiny of agencies implementing the law.

GOP lawmakers may be able to pick off unpopular provisions. Obama has already said he’s willing to “tweak” an IRS reporting requirement that small businesses find burdensome. Another target is a yet-to-be-named board with the power to make Medicare cuts. And look for a move to tighten restrictions on abortion coverage.

“It would be foolish to expect that Republicans will be able to completely reverse the damage Democrats have done as long as a Democrat holds the veto pen,” McConnell said, outlining the GOP agenda Thursday. “There’s just no getting around it.”

The GOP’s repeal strategy is fluid. Aides say no decision has been made on the first bill that House Republicans will take up in the new Congress, and party leaders have put taxes and government spending ahead of health care repeal as priorities.

“This is not a ‘Jeopardy!’ question where there is just one right answer,” said Rep. Joe Barton, R-Texas, a leader on health care. “House Republicans are committed to repealing the existing Obamacare bill. That’s not window dressing, but we are going to do a three-pronged approach. We’ll do repeal, we’ll do a reform bill, we’ll do a defunding bill. It’s all of the above.”

The repeal slogan energized big-government foes in the midterm elections, helping turn out Republican voters. However, trying to deliver on it could stir up a backlash. Exit polls on Election Day found voters divided. Forty-eight percent said they supported repealing the overhaul, but 47 percent said it should be expanded or kept as it is.

At his postelection news conference, Obama pretty much dared Republicans to follow through on their threat. Citing popular provisions of the law, such as help for seniors with high prescription costs and guaranteed coverage for people with medical problems, the president said, “I don’t think you’d have a strong vote for people saying … ‘Those are provisions I want to eliminate.’”

Mindful that some of the new benefits are popular, House Republican leader John Boehner has stressed that a “replace” measure preserving some aspects of Obama’s overhaul would go with legislation to repeal it. But not all his followers agree. Some conservatives want a straight vote on repeal that would leave the “replace” part for later.

“There is a critical difference whether the first fight is a repeal fight or it’s repeal and replace,” said Michael Needham, CEO of Heritage Action for America. “A straight repeal vote would go through the House with every Republican on it and a number of Democrats,” increasing pressure on the Senate.

And then there’s the wild card: federal budget politics.

If Obama and the Republicans can strike a grand bargain to reduce government deficits, it could open a path for GOP ideas such as curbs on malpractice lawsuits. Subsidies for the uninsured could be slowed or pared back, since the big coverage expansion under the law doesn’t start until 2014.

“It will be far easier to scale back an entitlement nobody has received than a program that people are already on,” said economist Douglas Holtz-Eakin, who served as a top policy adviser for 2008 GOP presidential candidate John McCain.

The last Republican to run the federal Health and Human Services Department isn’t forecasting repeal.

“I think it either fails in the Senate or is vetoed by the president,” said former HHS Secretary Mike Leavitt. “Ultimately, there will be some kind of a budget summit or bipartisan attempt to break the logjam, and many of the provisions of health reform will be put on the table at that time, and there will be changes.”

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Health-care law likely to remain intact under divided Congress, at least for now

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Can Republican lawmakers repeal the law?

Chances are slim to nil, at least through 2012. Although Republicans have regained control of the House, they will remain in the minority in the Senate. So it’s unlikely that Congress could pass a repeal bill. But even if that were to change, as long as President Obama remains in office, it’s a safe bet that he would veto such a measure.

What about repealing parts of the law?

Among the discrete provisions Republicans have discussed putting on the chopping block is the “individual mandate,” which requires virtually all Americans to obtain health insurance or pay a tax penalty. But any effort to strip the law of a provision that Democrats and the president consider essential to its overall functioning is likely to suffer the same fate as an outright repeal bill. Without the individual mandate, for instance, the law’s requirement that insurers stop denying coverage to people with preexisting conditions or set annual limits on benefits could fall apart because the risk pool could be skewed toward the sick.

On the other hand, Republicans could succeed in eliminating unpopular aspects that are less central to the law. A case in point is the “1099″ provision, which will require businesses to greatly expand their reporting to the IRS of any goods and services they buy. The measure was intended to raise money for the law by helping the IRS clamp down on tax evasion. But many small businesses say that complying with it will prove costly and onerous. Democrats and the president have expressed a willingness to modify or repeal it, as long as Congress finds an alternate funding source.

The Republicans’ majority in the House will give them the power of the purse. Could they use it to de-fund the law?

To some extent. But here, too, Republicans’ influence will be limited. The most substantial federal expenditures required by the law – the expansion of Medicaid contributions to help states cover a greater share of the poor, for instance, or federal subsidies to help individuals buy private insurance – won’t begin until 2014. And their funding sources were essentially locked in and automated by the law and will not be subject to Congress’s annual appropriations process over the next two years.

How about de-funding federal agencies responsible for implementing the health-care law, such as the Department of Health and Human Services or the IRS?

Opinions vary about the probable success of this tactic. The Congressional Budget Office has estimated that over the next 10 years, the administrative costs of implementation could run from billion to billion each for HHS and the IRS. But it’s unclear how much of that would need to come from budget increases. So far, both agencies have managed to make do with their existing budgets. HHS Secretary Kathleen Sebelius has said that even if her agency were not optimally funded over the next two years, she could find the staff and the means to continue implementing the law. Some conservative analysts are less sanguine, noting that the law requires that by 2013 HHS not only assess the readiness of states to run exchanges through which individuals and small businesses can buy private insurance, but that the agency be ready to step in with a federal version in case any states are found lacking.

House Republicans have also made clear that they plan to hold vigorous oversight hearings on the health-care law. How significant could those hearings prove?

In the long run, the Republicans’ newfound opportunity to hold hearings showcasing what they consider downsides of the law could be their most effective means of dismantling it; the hearings could lay the groundwork for a broad-based public repudiation of legislation that still divides Americans. Among others, Republicans hope to spotlight business owners who say they are hiring fewer workers because they cannot afford to offer the health insurance the law mandates, and individuals who say their premiums have skyrocketed because their insurers have been required to offer broader protections. But Democrats and the White House could also push back, using the hearings as an opportunity to sell Americans on the benefits of the law.

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