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Oct. 25, 2022 – Just when we thought this holiday season, finally, would be the back-to-normal one, some infectious disease experts are warning that a so-called tripledemic – influenza, COVID-19, and RSV – may be in the forecast.

The warning isn’t without basis. 

• The flu season has gotten an early start. As of Oct. 21, early increases in seasonal flu activity have been reported in most of the country, the CDC says, with the southeast and south-central areas having the highest activity levels. 
• Children’s hospitals and emergency departments are seeing a surge in children with RSV.
• COVID-19 cases are trending down, according to the CDC, but epidemiologists – scientists who study disease outbreaks – always have their eyes on emerging variants. 

Predicting exactly when cases will peak is difficult, says Justin Lessler, PhD, a professor of epidemiology at the University of North Carolina at Chapel Hill. Lessler is on the coordinating team for the COVID-19 Scenario Modeling Hub, which aims to predict the course COVID-19, and the Flu Scenario Modeling Hub, which does the same for influenza.

For COVID-19, some models are predicting some spikes before Christmas, he says, and others see a new wave in 2023. For the flu, the model is predicting an earlier-than-usual start, as the CDC has reported.  

While flu activity is relatively low, the CDC says, the season is off to an early start. For the week ending Oct. 21, 1,674 patients were hospitalized for flu, higher than in the summer months but fewer than the 2,675 hospitalizations for the week of May 15, 2022. 

As of Oct. 20, COVID-19 cases have declined 12% over the last 2 weeks, nationwide. But hospitalizations are up 10% in much of the Northeast, The New York Times reports, and the improvement in cases and deaths has been slowing down. 

As of Oct. 15, 15% of RSV tests reported nationwide were positive, compared with about 11% at that time in 2021, the CDC says. The surveillance collects information from 75 counties in 12 states. 

Experts point out that the viruses — all three are respiratory viruses —  are simply playing catchup. 

“They spread the same way and along with lots of other viruses, and you tend to see an increase in them during the cold months,” says Timothy Brewer, MD, professor of medicine and epidemiology at UCLA.

The increase in all three viruses “is almost predictable at this point in the pandemic,” says Dean Blumberg, MD, a professor and chief of pediatric infectious diseases at the University of California Davis Health. “All the respiratory viruses are out of whack.” 

Last year, RSV cases were up, too, and began to appear very early, he says, in the summer instead of in the cooler months. Flu also appeared early in 2021, as it has this year. 

That contrasts with the flu season of 2020-2021, when COVID precautions were nearly universal, and cases were down. At UC Davis, “we didn’t have one pediatric admission due to influenza in the 2020-2021 [flu] season,” Blumberg says. 

The number of pediatric flu deaths usually range from 37 to 199 per year, according to CDC records. But in the 2020-2021 season, the CDC recorded one pediatric flu death in the U.S.

Both children and adults have had less contact with others the past 2 seasons, Blumberg says, “and they don’t get the immunity they got with those infections [previously]. That’s why we are seeing out-of-season, early season [viruses].” 

Eventually, he says, the cases of flu and RSV will return to previous levels. “It could be as soon as next year,” Blumberg says. And COVID-19, hopefully, will become like influenza, he says.

“RSV has always come around in the fall and winter,” says Elizabeth Murray, DO, a pediatric emergency medicine doctor at the University of Rochester Medical Center and a spokesperson for the American Academy of Pediatrics. This year, children are back in school and for the most part not masking, she says. “It’s a perfect storm for all the germs to spread now. They’ve just been waiting for their opportunity to come back.” 

Self-Care vs. Not

RSV can pose a risk for anyone, but most at risk are children under age 5, especially infants under age 1, and adults over age 65.  There is no vaccine for it. Symptoms include a runny nose, decreased appetite, coughing, sneezing, fever, and wheezing. But in young infants, there may only be decreased activity, crankiness, and breathing issues, the CDC says.

Keep an eye on the breathing if RSV is suspected, Murray tells parents. If your child can’t breathe easily, is unable to lie down comfortably, can’t speak clearly, or is sucking in the chest muscles to breathe, get medical help. Most kids with RSV can stay home and recover, she says, but often will need to be checked by a medical professional.

She advises against getting an oximeter to measure oxygen levels for home use. “They are often not accurate,” she says. If in doubt about how serious your child’s symptoms are, “don’t wait it out,” she says, and don’t hesitate to call 911.

Symptoms of flu, COVID, and RSV can overlap.  But each can involve breathing problems, which can be an emergency. 

“It’s important to seek medical attention for any concerning symptoms, but especially severe shortness of breath or difficulty breathing, as these could signal the need for supplemental oxygen or other emergency interventions,” says Mandy De Vries, a respiratory therapist and director of education at the American Association for Respiratory Care. Inhalation treatment or mechanical ventilation may be needed for severe respiratory issues.

Precautions

To avoid the tripledemic – or any single infection – Timothy Brewer, MD, a professor of medicine and epidemiology at UCLA, suggests some familiar measures: “Stay home if you’re feeling sick. Make sure you are up to date on your vaccinations. Wear a mask indoors.”

Antiretroviral therapy, or ART, is a safe and proven way to treat HIV. Your doctor will want you to start right away — usually the same day you’re diagnosed. This is called rapid-start ART. Early and effective treatment can help you live a normal life. It can also lower the chances you’ll pass the virus to someone else.

The sooner you start ART, the better. That’s true even if you feel good.

“There’s no upside to waiting,” says Shannon Galvin, MD, associate professor of medicine and infectious diseases at Northwestern Medicine. “Everyone who has HIV will benefit from being on treatment, no matter what their T-cell count is.”

Effective ART can lower your viral load so much that blood tests won’t be able to find it. That doesn’t just keep you well. It means there’s pretty much no chance that you’ll sexually transmit the virus to someone else. That’s called “undetectable equals untransmittable.” If you reach this state fast, you may feel more in control and hopeful about your condition, says Gregory Huhn, MD, associate professor of medicine and infectious diseases at Rush University Medical Center.

ART can help you stay healthy. But it’s not a cure for HIV. You’ll need to take your medicine every day. If you have questions about your treatment, talk to your doctor before you start. They can help you find a plan that works for you.

How Does ART Treat HIV?

This combo of drugs can lower the amount of HIV in your blood, which is called your viral load. This keeps up your CD4 count. The higher this number, the more T cells you have and the better your immune system works. ART also lowers your HIV-related immune activation. This is inflammation that can hurt your heart, brain, bones, and other organs.

Basically, ART makes it less likely you’ll get sick from HIV. And that helps you live longer.

“If you take a 20-year-old with a CD4 count above 500, who starts ART immediately after diagnosis — and they don’t have hepatitis B, C, or other comorbidities — their life expectancy is about the same as that person without HIV,” Huhn says.

Who Should Start ART Right Away?

In the past, doctors gave rapid-start ART to people with a very low CD4 count. But now, anyone with HIV is likely to get it. “We have hard data that shows everybody (with HIV) lives longer and healthier if they’re on antiretrovirals,” Galvin says.

ART is even more important for certain groups. That includes people who:

• Are pregnant. You’re less likely to pass HIV to your baby if you have an undetectable viral load. If you’re already on ART, keeping taking your medicine. But if you’re not, talk to your doctor about how you can start treatment right away.
• Have a low CD4 count. People with a CD4 count less than 200 are at high risk for becoming ill. In fact, a CD4 count this low means you have AIDS.
• Have an AIDS-defining condition. These are infections and cancers that are especially serious for people with HIV.

Should Anyone Delay ART?

There are very few people who should wait to begin ART, Huhn says. But sometimes you may need to treat certain infections first.

Your doctor may put off your ART if you have:

Your doctor may also want to first treat any serious mental health conditions, Huhn says. Untreated psychological or substance abuse problems can make it harder for you to keep up with treatment.

What If You’re Not Ready?

It’s normal to need some time to take in your diagnosis. It’s still considered rapid start if you begin ART within 7 days. What’s most important is that you’re ready to stay with treatment once you start. “There are a few people who have to think about it, and they should be given that opportunity,” Galvin says. “We just want to make sure that we’re starting something we have a plan to continue.”

If you’re living with advanced prostate cancer, you’ve probably heard others tell you to “advocate” for yourself. But just what’s involved in being a self-advocate? It means taking an active role in your care by listening, learning, asking questions, and connecting with others.

Being your own advocate doesn’t mean taking sole responsibility for your cancer treatment. Instead, it helps put you in a team mindset and learn that you’re a key part of your health care team. When you take an active role in your prostate cancer treatment, you help make sure that you’re getting the care that works best for you.

Learn About Your Condition

Understanding your cancer and its treatment can help you deal with the emotional rollercoaster that can go along with managing the disease.

“Often, when people are diagnosed with prostate cancer, they feel powerless and shocked,” says Ramdev Konijeti, MD. He’s the director of the genitourinary cancer program at Scripps MD Anderson Cancer Center. “But education is information, and information is power.”

Your doctor or clinic should be able to point you to the best resources for understanding your cancer better. In general, websites that end with .gov, .org, or .edu, or cite their sources, will have the most reliable information.

“As with any large body of information, you can find misinformation,” Konijeti says. “There is plenty of available public information about prostate cancer that minimizes the impact of the disease or that inappropriately magnifies the impact of the disease.”

Murray Wadsworth, 63, says he became a “patient detective” after his advanced prostate cancer diagnosis 6 years ago. “I had to learn how to look for clues and get rid of everything that wasn’t right for me,” he says. “I say ‘patient detective’ because I want to remind myself I am just the patient. I don’t want to get ahead of the doctors too much.”

Some websites that can help you learn more include:

• American Cancer Society
• Cancer.net
• Prostate Cancer Foundation
• National Cancer Institute
• Urology Care Foundation
• National Comprehensive Cancer Network

Ask Questions

You might feel nervous asking medical experts for more information, better explanation, or even a second opinion, but it’s your right to find out as much as you can about your cancer and treatment.

A good medical team should welcome your questions, Konijeti says. “The overwhelming majority of physicians who care for patients with prostate cancer understand the complexity of your experience and they want to help.”

Keep a list of concerns to help you remember what you want to ask in each visit. Some things you might want to know include:

• Is there any evidence my cancer has spread?
• What are my treatment choices? Which do you think is best for me?
• What’s the goal of my treatment?
• What side effects might I have?
• What should I do to get ready for my treatment?
• How often will I have treatments and how long will they last?
• Will I need to miss work during treatment?
• What are the costs involved?
• Should I consider joining a clinical trial?

“Understanding where you fit on the spectrum of the disease, how treatment may or may not affect you, and how that plays into your overarching life goals is extremely important,” Konijeti says.

For Wadsworth, it was important to understand exactly what he was facing, in plain language.

“There were lots of terms thrown around like ‘undetectable’ and ‘recurrence’ and ‘relapse’ and ‘no evidence of disease,'” he says. “So I would ask very specific questions, like, ‘Can I be cured?’ I needed them to cut to the chase and tell me: What does all this mean?”

Connect With Others

Many communities have local prostate cancer support groups, organized either by patients or health professionals. These groups can be useful for getting to know others who may also have gone through diagnosis and treatment.

Wadsworth says he discovered several prostate cancer groups on social media. “I’ve actually learned from a few men by reading what they post and dialoguing with those who are further down the road than I am with recurrence.”

Wadsworth and Konijeti caution that while these groups can be a great way to build community, they can sometimes lead to misinformation.

“Prostate cancer is a very heterogeneous disease and not everyone shares similar experiences,” Konijeti says. “And treatment for prostate cancer is not necessarily ‘one size fits all.’ Just as the disease exists on a spectrum, so do the treatments. The choice for, or intensity of, treatment can often depend on the degree of aggressiveness of the disease.”

So as a general rule, groups are great for emotional support, relationships, shared stories, and advice, but rely on the counsel of medical experts when it comes to risks, benefits, and alternatives to screening and treatment.

Oct. 25, 2022 – When 32-year-old Brittany Dicks was diagnosed with stage II triple-negative breast cancer in January 2022, she wasn’t worried about the cost of treatment. A medical assistant in Charleston, SC, Dicks had full-time employment with health benefits. 

But when she wasn’t able to work for several months due to chemotherapy and its side effects, Dicks lost her job. Her health insurance coverage ended in May. And although she filed for Medicaid at the beginning of June, it wasn’t approved until September. 

Meanwhile, Dicks still needed treatment. She estimates that she ran up close to $20,000 in medical debt while finishing chemotherapy during the 4 months she was uninsured. 

The surgeon she had seen since her diagnosis dropped her as a patient when she could no longer pay her bills. That left her delaying a much-needed mastectomy. 

“I don’t sleep at night,” says Dicks, a single mom of two kids, ages 3 and 11. “Mentally, I’m drained. Just because I have cancer, doesn’t mean the bills aren’t due every month.” 

As soon as she felt well enough over the summer, she started working as a part-time delivery driver for DoorDash to help pay for food and gas.

But that was just a Band-Aid. Even when her new insurance kicked in, covering the costs of daily life remained a struggle. 

Dicks is still in deep medical debt. Medicaid has covered new medical expenses, and she hopes it will reimburse her for the debt she incurred over the summer, while she waited for her coverage to kick in. So far, though, Medicaid has not touched her $20,000 debt.

“I fear that I’m not going to be able to dig out of this hole,” she says. 

Researchers who study the financial impacts of cancer have a term for Dicks‘s experience: Financial toxicity. 

It’s a catchall term for the burden many Americans with cancer have.

“Financial toxicity is a multidimensional concept. There‘s both a material burden and a psychosocial one,” says Grace Li Smith, MD, PhD, a radiation oncologist at the University of Texas MD Anderson Cancer Center in Houston.

Financial toxicity consists of the direct costs of medical care, including copays, deductibles, and other out-of-pocket expenses for treatment and medications, as well as the indirect costs from loss of income or savings that come with cancer care. 

Researchers are also now beginning to understand the psychological effects these financial burdens can have on patients and their families

“Financial toxicity is not unique to the patient,” says Li Smith. It “very directly impacts the whole family or household.”

The Stifling Financial Pressures

Early in her career, Li Smith was already seeing how her patients’ worries extended beyond their physical disease. 

One of her first patients told her their greatest worry wasn’t whether the treatment would work or what physical toxicity to expect; it was how they would pay for their care.

“There was much more anxiety and true distress about the financial burden than about the treatment itself,” Li Smith says. 

This fear about the costs of cancer care is well-founded. In the United States, cancer treatment costs reached an estimated $150 billion in 2020 and continue to rise. Patients shoulder a significant portion of that burden – with one study estimating that patients paid $21 billion for their cancer care in 2019. 

The burden is often made worse by decreased income. Between 40% and 85% of patients with cancer needed to take time off work or quit their jobs during treatment. And for those, like Dicks, who find themselves with no insurance, out-of-pocket costs can quickly skyrocket.

In fact, one study of newly diagnosed cancer patients over age 50 reported that more than 42% of patients fully depleted their financial assets and around 30% incurred debt by the second year of their diagnosis. 

Younger adults may be even more financially vulnerable. A study of patients in Washington state found that those under 65 – who represent about half of cancer cases– were 2 to 5 times more likely to declare bankruptcy than patients over 65. 

In another study published last July, Li Smith and colleagues found that younger patients, ages 18 to 64, had more money troubles, which meant less money for food, more problems with staying on their medications, as well as greater distress and anxiety overall. In fact, younger adults were over 4.5 more likely to face severe financial toxicity, compared with older adults, and about 4 times more likely to have severe psychological effects from this burden.

The distress, if left unchecked, can spiral out of control. 

Molly MacDonald had just gone through a financially devastating divorce in 2005 when she was diagnosed with breast cancer. Recently out of work, MacDonald ended up with COBRA insurance – a federal law that allows people to stay on their former employers’ health plan temporarily, but they have to pay the full cost themselves. She was dealing with a $1,300 monthly premium, meaning the mother of five had no financial safety net. She risked having her car repossessed and her utilities shut off. 

“I gave tentative thought to how I could take my life and make it look like an accident,” says MacDonald, of Bloomfield Hills, MI. “I thought the kids would be better off without me.”

For some, the loss of income can be even more worrisome than the medical bills. Some patients may go back to work during treatment, often against medical advice. 

When Stephanie Caputo, 43, of Monroe, NJ, began treatment for stage III breast cancer in 2021, her doctor recommended she stop working. Treatment would make her immunocompromised, and her job in a medical clinic could expose her to harmful germs, including the coronavirus. 

Caputo went on disability and received $900 every 2 weeks. But that wasn’t enough to pay her mortgage, let alone cover her other monthly expenses as a single mother of four teenagers. 

After finishing chemotherapy, and during radiation, she went back to work, part-time, against her doctor‘s advice. 

“My doctor is telling me I can’t work, but I also can’t have my house go into default,” Caputo says. 

But being on her feet through 12-hour shifts made treatment side effects, especially back and joint pain, kick into overdrive. “The physicality of my job was really difficult to tolerate,” she says.

The physical burden was too great to take on more work, but the extra money also wasn’t enough to keep her afloat. Fortunately, her brother stepped in and covered 6 months of her mortgage payments.

Financial Toxicity Impacts Families

Although financial toxicity research to date has largely focused on the patient, researchers are also starting to understand that family members and caregivers often share in the burden. 

“We are just at the beginning of realizing that this is a real problem,” says Fumiko Chino, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center in New York City. 

Chino and colleagues recently showed that family members of patients with cancer were more likely to delay or forgo medical care than family members of people without cancer. The study, published in July, found the effect was greatest among family members of younger adults with cancer. 

“The caregiver and family burden related to cancer diagnosis and treatment is really underappreciated,” says Chino. “Family members and caregivers are neglecting their own health concerns, passing up career opportunities, struggling with financial concerns.”

Chino speaks from personal experience. When her fiancé, later her husband, was diagnosed with neuroendocrine carcinoma in 2005, Chino quit her job as art director at a television production company to take care of him.

The couple, both in their 20s, struggled to afford his care. Chino put her own dental, medical, and mental health care on hold. She never, for instance, went to physical therapy to address injuries she got from sleeping in hospital chairs and moving around her husband, who was over 6 feet tall. At one point, she walked with a limp.

Chino’s husband passed away in 2007, and even 15 years later, her injury from sleeping in hospital chairs remains “a significant physical burden,” she says. But like many caregivers, “I wasn’t really thinking about my own health.”

Danielle Hadfield, 35, an ER nurse in Rochester, NY, also delayed her own care when her mom got sick. 

She quit her job shortly after her mom was diagnosed with cholangiocarcinoma in August 2020. Hadfield knew her mom, who lived 3.5 hours away in Albany, NY, would need a lot of care in the upcoming months. 

“I knew this was going to be the last year or so of her life, and I wanted to be there for her,” she says.

When Hadfield quit her job, she and her husband – who was self-employed – purchased health insurance coverage through the New York State Marketplace. The monthly insurance payments for Hadfield (who was pregnant with her second child), her husband, and their toddler cost as much as the family‘s monthly mortgage payments. 

In addition to providing child care for her young daughter and making frequent trips to Albany, Hadfield began a side business as a legal nurse consultant, working mostly at night, to replace part of her lost income. During this time, she began to have pain attacks that would migrate through her body, along with tongue and facial numbness that came and went. She ignored these health issues for nearly a year, until after her mom died in November 2021.

Only after her mother passed away did Hadfield begin seeking answers to her own pain. In September 2022, she finally got them. She had a nerve condition called small fiber sensory neuropathy. 

But even with a diagnosis, she is still facing more tests to root out the cause and understand the best treatment. 

Is Help Out There?

What can doctors do to help patients and families at risk for financial toxicity? 

Specific ways to deal with financial toxicity do not exist in most professional guidelines, nor are there standard screening tools to identify it, says Li Smith. 

These gaps put pressure on doctors to ask about financial barriers and concerns, but most do not know how to broach the topic or how to help. “Physicians may not know how to fix the problem or what resources exist,” Li Smith says. 

Patients and family members, on the other hand, are often reluctant to bring up cost with doctors. Some may be ashamed to talk about their financial problems, while others may fear doing so will prevent them from being offered the best possible treatments, says MacDonald, the mother of five who thought about taking her own life.

But, experts say, financial toxicity needs to be dealt with head-on. That means involving financial navigators or counselors and social workers who can, for instance, help patients and families find financial support for their basic living expenses. 

From a research perspective, more clinical trials should include financial toxicity outcomes, says Joshua Palmer, MD, a radiation oncologist at Ohio State University in Columbus. 

Palmer and colleagues recently showed that the number of radiation therapy clinical trials including financial toxicity results increased significantly from 2001 to 2020, though the rate remains low. 

“Financial burden is part of the broader discussion about shared decision making,” says Palmer. 

In shared decision making, doctors discuss the risks and benefits of different treatment options, empowering the patient to make an informed choice with the doctor. 

What we want to avoid is patients feeling like they will get inferior care, if they have financial barriers, Palmer says.

And every little bit can help. In 2006, MacDonald started the Pink Fund – a nonprofit to help patients with cancer cover non-medical cost-of-living expenses. Both Stephanie Caputo and Brittany Dicks received grants from the Pink Fund. For Caputo, the funds covered 2 months of car payments, and for Dicks, it covered 2 months of rent.

While the one-time grant was a big help, said Dicks, “cancer is an everyday thing.” And “we all deserve peace of mind” when trying to heal.