Annie Krause moved into a nursing home in Detroit in 2015, when she was 98 years old. She had grown frail. Arthritis, recurrent infections and hypertension had made it difficult for her to manage on her own.
When the facility’s doctor examined her, he found a mass in Krause’s breast and recommended a biopsy — standard procedure to determine what sort of tumour this was and, if it proved malignant, what treatment to pursue. Once diagnosed, breast cancer almost always leads to surgery, even in older women.
“If she were a passive person, she would have had a lumpectomy,” said Krause’s granddaughter, Dr Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston. “But my grandmother was very strong-willed. She said no, no, no, she didn’t want any procedure.”
That didn’t stop the doctor from recommending a biopsy, however.
Having spent years studying how best to inform older women about breast cancer, Schonberg said that patients’ decisions — about screenings and treatments — have proved stubbornly resistant to change.
She told me about her family’s situation in the wake of a recent study by researchers at the University of California San Francisco. Published in JAMA Surgery, it followed nearly 6,000 nursing home residents who underwent inpatient breast cancer surgery over a 10-year period.
It’s the most common cancer operation for nursing home residents, the researchers reported. Yet Medicare data showed that as a group, these women did not fare well.
“The trajectories for these patients tends to be poor to begin with,” said Dr Victoria Tang, a geriatrician and the study’s lead author. Almost by definition, women in nursing homes have serious health problems that already portend limited life expectancies.
The women in the study (average age 82) had high rates of diabetes, arthritis, heart failure and stroke. They needed considerable help with everyday tasks. Well over half were cognitively impaired.
Yet their surgeons tended to operate aggressively. Though about 11 per cent had a lumpectomy, more than a quarter underwent a mastectomy, removal of the entire breast. In more than 60 per cent, surgeons also removed underarm lymph nodes, a procedure usually conducted to help determine future treatment, but one that can cause pain and infection, with arm swelling that hampers mobility.
In younger and healthier groups, breast cancer surgery is considered low risk. “A lumpectomy is seen as routine, no big deal,” Tang said. “It can be done as an outpatient.”
But for these women, “the surgical treatment for breast cancer may have been worse than the breast cancer itself,” said Dr Rita Mukhtar, a breast cancer surgeon and a co-author of the study.
Within a month after surgery, 2 to 8 per cent of the patients in the study had died, a very high mortality rate. Those undergoing lumpectomy — perhaps, the authors hypothesize, because those women were sicker and deemed less likely to survive more invasive surgery — were most likely to die.
Surgeons and hospitals (and Medicare) pay close attention to the 30-day mortality rate, but most patients and families expect more, months or years of extended life in exchange for the rigors of surgery.
But within a year, 29 to 41 per cent of these patients had died, depending on the type of surgery they’d had — another very high mortality rate.
Of those who survived a year, about 60 per cent experienced a decline in function. “A lymph node dissection might disable you and leave you in pain, so you’re less able to dress or bathe or even feed yourself, Tang said.
Of course, nursing home residents do decline and die, with or without surgery. But that, Mukhtar said, was the point.
“We’re taking people who are more likely to die of something else, and putting them through hospitalization and surgery, with all those risks,” she said, citing those including infection, falls and delirium. “By operating on them, we may be diminishing their quality of life for their remaining days.”
Given a clearer sense of the risks, patients and families might opt for less invasive treatments. Hormone therapy, like tamoxifen or aromatase inhibitors taken orally, slows the progression of certain kinds of tumors. Radiation may also control tumors, with fewer dangers than surgery.
In cases where a tumour grows through the skin and causes pain or bleeding, of course, surgery becomes a palliative response.
But it takes more than 10 years after screening to prevent a single breast cancer death for 1,000 patients screened, if they’re of average risk. So researchers say mammograms (and colon cancer screening, which involves a similar time lag) are most useful for those with life expectancies greater than a decade.
Few women in nursing homes will live that long. Many who develop breast cancer will experience no symptoms, and would never have known they had it without a physical exam or continuing mammograms.
Like any test or procedure, mammography involves risks: additional screenings, biopsies, complications of biopsies and treatment, and the anxiety the whole process creates.
The US Preventive Services Task Force doesn’t recommend mammograms for women over 75 because there’s insufficient evidence to assess benefits and harms. Older women have largely been excluded from clinical trials.
Since many older women have been dutifully having mammograms for decades anyway, Schonberg developed a brochure called “Should I Continue Getting Mammograms?”
It explains procedures, helps women assess relevant health factors and points out that over age 75, screening 1,000 women prevents only one breast cancer death over five years, while generating 100 false positives. (There’s also a version for women over 85.)
Distributing the brochure to 45 women, Schonberg determined that it had some impact. After using it, women were more knowledgeable and more likely to discuss the decision with their doctors. Yet 60 per cent still had another mammogram
She has since completed a broader study, being prepared for publication, involving 541 women over 75. Here, too, preliminary results show that the proportion who had another mammogram dropped only slightly after using the brochure, from 61 to 56 percent — a modest drop that demonstrates women’s reluctance to discontinue screening.
These subjects were not nursing home residents, and it might make sense for them to use other yardsticks besides age in their decision-making.
Mukhtar has performed breast cancer surgery on patients in their 50s and 60s, for instance, who had serious medical problems beforehand, leading to troubling complications afterward. But she also operated on healthy patients in their 80s who recovered well.
Nursing home residents are already in poor health, however. “It’s likely the surgery didn’t help them live longer, and certainly not better,” Schonberg said.
As for her grandmother, Annie Krause, she declined the biopsy and Schonberg supported her decision.
“In a 98-year-old, it probably is breast cancer,” Schonberg said. “But she didn’t want any more medical interventions. She was focused on optimizing her quality of life.”
Krause died two years later, after a stroke.
World Bank pushes G-20 to extend debt relief to 2021
World Bank Group President David Malpass has urged the Group of 20 rich countries to extend the time frame of the Debt Service Suspension Initiative(DSSI) through the end of 2021, calling it one of the key factors in strengthening global recovery.
“I urge you to extend the time frame of the DSSI through the end of 2021 and commit to giving the initiative as broad a scope as possible,” said Malpass.
He made these remarks at last week’s virtual G20 Finance Ministers and Central Bank Governors Meeting.
The World Bank Chief said the COVID-19 pandemic has triggered the deepest global recession in decades and what may turn out to be one of the most unequal in terms of impact.
People in developing countries are particularly hard hit by capital outflows, declines in remittances, the collapse of informal labor markets, and social safety nets that are much less robust than in the advanced economies.
For the poorest countries, poverty is rising rapidly, median incomes are falling and growth is deeply negative.
Debt burdens, already unsustainable for many countries, are rising to crisis levels.
“The situation in developing countries is increasingly desperate. Time is short. We need to take action quickly on debt suspension, debt reduction, debt resolution mechanisms and debt transparency,” said Malpass.
Kenya’s Central Bank Drafts New Laws to Regulate Non-Bank Digital Loans
The Central Bank of Kenya (CBK) will regulate interest rates charged on mobile loans by digital lending platforms if amendments on the Central bank of Kenya Act pass to law. The amendments will require digital lenders to seek approval from CBK before launching new products or changing interest rates on loans among other charges, just like commercial banks.
“The principal objective of this bill is to amend the Central bank of Kenya Act to regulate the conduct of providers of digital financial products and services,” reads a notice on the bill. “CBK will have an obligation of ensuring that there is fair and non-discriminatory marketplace access to credit.”
According to Business Daily, the legislation will also enable the Central Bank to monitor non-performing loans, capping the limit at not twice the amount of the defaulted loan while protecting consumers from predatory lending by digital loan platforms.
Tighter Reins on Platforms for Mobile Loans
The legislation will boost efforts to protect customers, building upon a previous gazette notice that blocked lenders from blacklisting non-performing loans below Ksh 1000. The CBK also withdrew submissions of unregulated mobile loan platforms into Credit Reference Bureau. The withdrawal came after complaints of misuse over data in the Credit Information Sharing (CIS) System available for lenders.
Last year, Kenya had over 49 platforms providing mobile loans, taking advantage of regulation gaps to charge obscene rates as high as 150% a year. While most platforms allow borrowers to prepay within a month, creditors still pay the full amount plus interest.
Amendments in the CBK Act will help shield consumers from high-interest rates as well as offer transparency on terms of digital loans.
Scope Markets Kenya customers to have instant access to global financial markets
NAIROBI, Kenya, Jul 20 – Clients trading through the Scope Markets Kenya trading platform will get instant access to global financial markets and wider investment options.
This follows the launch of a new Scope Markets app, available on both the Google PlayStore and IOS Apple Store.
The Scope Markets app offers clients over 500 investment opportunities across global financial markets.
The Scope Markets app has a brand new user interface that is very user friendly, following feedback from customers.
The application offers real-time quotes; newsfeeds; research facilities, and a chat feature which enables a customer to make direct contact with the Customer Service Team during trading days (Monday to Friday).
The platform also offers an enhanced client interface including catering for those who trade at night.
The client will get instant access to several asset classes in the global financial markets including; Single Stocks CFDs (US, UK, EU) such as Facebook, Amazon, Apple, Netflix and Google, BP, Carrefour; Indices (Nasdaq, FTSE UK), Metals (Gold, Silver); Currencies (60+ Pairs), Commodities (Oil, Natural Gas).
The launch is part of Scope Markets Kenya strategy of enriching the customer experience while offering clients access to global trading opportunities.
Scope Markets Kenya CEO, Kevin Ng’ang’a observed, “the Sope Markets app is very easy to use especially when executing trades. Customers are at the heart of everything we do. We designed the Scope Markets app with the customer experience in mind as we seek to respond to feedback from our customers.”
He added that enhancing the client experience builds upon the robust trading platform, Meta Trader 5, unveiled in 2019, enabling Scope Markets Kenya to broaden the asset classes available on the trading platform.