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Vol. 8, No. 2 · June-July 2004 · Editor: Martha L. Golar, Esq.
· Current News Items · Report Card on External Appeal Laws in NYS · February Program · Calendar of Events JALBCA Annual Dinner and Awards Presentation  JALBCA’s annual dinner was held on May 10, 2004, at The Water’s Edge, Long Island City. Chief Judge Judith Kaye installed the newly elected officers and newly elected members of the Board of Directors and Advisory Board, including the re-installation of Co-Presidents Hon. Shirley Werner Kornreich and Roy Reardon, Esq.In addition, awards were granted to people and institutions which have made special contributions to JALBCA and the providers who support the cancer community. JALBCA award recipients included: John D. Feerick, Esq., recipient of the Special Recognition Award, for his past and continued commitment to public service; Beth Israel Medical Center, recipient of the Leadership Achievement Award, for its work in early detection and supportive care for advanced disease, including services that are usually associated with end-of-life treatment for progressive cancer, pain management, evaluation and treatment of fatigue, worry, and spiritual and practical questions; and JALBCA Secretary Susan Solomon, Esq., recipient of the Volunteer Service Award, for her extraordinary work in coordinating and organizing JALBCA’s annual Courthouse Alert, which involves arranging for mobile mammography vans and dissemination of material about breast and prostate cancer to the public, lawyers and court personnel who frequent New York courthouses. The event was very successful and capped off a very productive year for JALBCA.  
Current News items Antibiotics and Breast Cancer The February issue of The Journal of the American Medical Association (JAMA) published alarming findings from an epidemiological study – not a clinical trial – that there is a potential link between antibiotics and developing breast cancer. This was a study of more than 10,000 women in the State of Washington – 2,266 women 20 and older who developed invasive breast cancer and who were compared with 7,953 women who did not get breast cancer. Researchers found that those women who used the most antibiotics had double the chance of developing breast cancer, and this association was consistent for all forms of antibiotics and the risk increased with the number of prescriptions. Those with double the risk had used more than 25 prescriptions (or who took the drugs for at least 501 days) over an average of 17 years – less than two prescriptions a year. Presently, there are only theories as to how antibiotics could increase the risk for breast cancer. For example, perhaps antibiotics affect bacteria in the digestive system in ways that interfere with how the body metabolizes foods that protect against cancer, or perhaps antibiotics affect the immune system or inflammation in ways which increase cancer risk. In all events, until further studies are done to validate the association, it is likely that the study’s findings will lead to a more judicious use of antibiotics, e.g ., not prescribing antibiotics for conditions in which they are ineffective, such as colds and other illnesses caused by viruses. There was apparently a second study, one conducted in 2000 in Finland, which also drew a connection between antibiotics and breast cancer. In that study, scientists found that women younger than 50 who had taken antibiotics for urinary tract infections also had an elevated risk for getting breast cancer. It was not clear in that study, however, that the results were tied to all classes of antibiotics. Report Card on External Appeal Laws in NYS By way of background, the New York External Appeal Law was passed and signed into law in 1998. It expands the protections of the 1996 Managed Care Reform Act, which added a Title I to Article 49 of the Insurance Law and the Public Health Law. Protections included in the Managed Care Reform Act included access to specialists, continuity of care when a provider no longer participates in a network, a prudent layperson standard for coverage of emergency services, mandatory disclosure of coverage information, prohibitions on gag clauses in subscriber contracts, and requirements that health plans have procedures in place for consumers to appeal coverage denials. In order to appeal coverage denials, two different procedures exist , i.e., a grievance procedure and a utilization review procedure. The former is required only by managed care plans. The latter is used to determine whether services are medically necessary, experimental or investigational. Health plans must have both a standard and an expedited appeals process for a member to appeal a utilization review denial. The External Appeal Law added the ability of consumers to obtain an independent review if a health plan upholds an adverse utilization review determination that services are not medically necessary or are experimental or investigational. The external appeal application must be sent to the NYS Insurance Department (“NYSID”). Since July 1, 1999, the NYSID has tracked all external appeal requests that it received and the statistics as of December 31, 2002 are as follows: 1,427 external appeal requests have been rejected as ineligible for external appeal – the most frequent reason for rejection being that the application is incomplete and the applicant has not provided the missing information after two requests are made by the NYSID. 722 appeals were closed because a health plan reversed an adverse determination during the external appeal process. 2971 appeals were closed as a result of a decision being rendered by an external appeals agent. The three certified external appeal agents in NY are Medical Care Management Corporation (MCMC), Island Peer Review Organization (IPRO ) and Hayes Plus. In prior years, external appeals agents overturned medical necessity denials (the most frequent types of services appealed tend to be surgical services, inpatient hospital services, mental health services, physical therapy, prescription drug coverage and chiropractic services) in about half of all cases, but only reversed experimental/investigational treatment denials in about one of every three cases. In 2001 and 2002, this proportion changed somewhat – in 2002, 44% of medical necessity denials were overturned in whole or in part, and 50% of experimental/investigational treatment denials were overturned. Statistics are also tracked for expedited external appeal calls and decisions. Expedited external appeals occur when the patient’s attending physician attests that a delay in providing the health care service would pose an imminent or serious threat to the health of the patient. These decisions are made by an external appeals agent in 3, instead of the standard 30, days. In 2002, external appeal agents overturned health plan denials in whole or in part in 49% of expedited cases (vs. 44% of standard appeal cases). Detailed information, including statistics on external appeal results by health plan, are available on the NYSID website, where the annual report on external appeals can be located. The report for the period ending December 31, 2003, is not yet posted. External appeal information is also available in the NYSID website at www.ins.state.ny.us or by calling 1-800-400-8882. February Program JALBCA held a particularly interesting program in February 2004, with a presentation by Mitchell Gaynor, MD, Senior Medical Oncology Consultant at the Strang Cancer Prevention Center, and Assistant Clinical Professor of Medicine at Weill-Medical College of Cornell University. Dr. Gaynor addressed the membership on “integrative oncology,” indicating that there were certain concrete things one can do to decrease the risk of cancer. Among Dr. Gaynor’s recommendations are special attention to nutrition, exercise and taking note of the role of stress and its impact on the immune system. He noted that depression can increase stress and negatively impact the immune system. As for diet, 70% of cancer cases in this country are believed to be related to nutrition. Citing the fact that Japanese women have one-seventh of the risk of breast cancer as compared to American women, Dr. Gaynor endorsed the use of ample servings of green tea and of including omega-3 fatty acids (i.e., eating salmon), as well as soy and seaweed products in one’s diet. Dr. Gaynor spoke about the precautionary principle, i.e., that medical practitioners should act on facts and the most accurate interpretation of those facts, using best scientific information available – as opposed to the “wait and see” approach of deferring conclusions about health risks until lengthy studies are analyzed. Dr. Gaynor has an integrated approach to oncology practice – combining the best that medical science has to offer in terms of chemotherapeutic advances – monoclonal antibody therapies – along with incorporating mindbody practices and nutritional modalities. On the issue of antioxidants, Dr. Gaynor is a fan of green tea and cruciferous vegetables and other components in the diet. It is now known that various nutrients affect genes that contribute to promoting or preventing cancer. Nutrients can basically turn cancer cells on or off and affect their growth and proliferation. Antioxidants can enhance the transcription of our detoxification enzymes, which break down many of the carcinogens in our environment. Antioxidants such as Vitamin A, Vitamin C, Vitamin E and nutrients found in soy and turmeric are valuable when taken wisely, preferably under a doctor’s direction. These nutrients can affect the immune system, which is largely responsible for preventing a recurrence of cancer. Dr. Gaynor readily expressed his concern for the environment, which is an important factor in making advances in integrative oncology. He cautioned that the environmental link to cancer is manifest – citing an increase in 30% in childhood lymphoma since 1973. There has also been an increase in a certain type of childhood leukemia and also brain tumors in children over the past several decades. Dr. Gaynor reiterated the cautionary tale of how it took 50 years before there was general acceptance of the premise that cigarettes cause lung cancer. The manipulation of studies and statistics can be mitigated by employing the precautionary principle, acting on facts, rather than ignoring them. He stated that, in time, it is possible that an environmental connection will be made to attention deficit disorder, autism and different types of cancer. He also cautioned that we are losing species of plants and animals each year, and the level of pollution and global warming is implicated in the increase of certain diseases. Cancer, he said, is a process that takes several decades. A pre-carcinogen phase is the beginning of the process. A chemical in the environment can damage DNA and therefore alter cells – this is known as initiation. It is widely believed that the time of the most rapid cell division is the time of greatest vulnerability in terms of cancer. This translates into the period that we are in utero and our adolescent years. Carcinogens cause DNA mutations, impede DNA synthesis and DNA repair. Dr. Gaynor spoke briefly concerning the Long Island breast cancer study, where it was found that certain organo-chlorines were at higher levels in women with breast cancer. One such compound is DDT, known as a “weak estrogen," however, the exact mode of synergy with carcinogens in our bodies remains unknown. Dr. Gaynor pointed out that DDT has a 47-year half life (meaning that half of the amount a person is exposed to is out of the system in 47 years). Significantly, according to Dr. Gaynor, this can be compared to natural estrogen, which is out of the system in a few hours. Also, the synergy of various exposures cannot be ignored – a smoker will have an 11-fold increase in the risk of cancer as compared to a non-smoker – and if the person is asbestos-exposed, his/her lung cancer risk is even five times greater. This means that you have 55 times greater a risk if you both smoke and had asbestos exposure because of the synergistic effect of the respective carcinogens. Persistent organic pollutants (“pops”), such as dioxin, continue to pose a threat. Dioxin is passed readily in breast milk and there is a steady supply of this toxin from large recycling plants that burn tires. Dr. Gaynor warned that industry will try and convince us that “dilution is the solution to pollution,” which accounts for why we see larger and larger smokestacks, which are designed to spread toxic ash over larger surface areas. The dioxin level in the Great Lakes has caused so much pollution that it has greatly diminished the fish population and increased the rate of lymphoma, according to Dr. Gaynor. He also noted that, although one cannot burn toxic waste in populated areas, there is a loophole for cement kilns, which is categorized as “recycling." This is a particular risk which was emphasized during his presentation. What to do? Besides whatever stirrings one might have to become active in environmental matters, dietary changes are a good start. Increase your intake of green tea (several cups a day); salmon; cruciferous vegetables such as broccoli, brussel sprouts, cabbage and soy products. Dr. Gaynor also endorsed red wines in moderation (favoring the Bordeaux Cabernets), and the addition of rosemary and curry in the diet. Selenium is also a favorite of Dr. Gaynor, which can be found in eggs, beef, turkey, veal, Brazil nuts and cashews. JALBCA is very grateful to Dr. Gaynor for a provocative lecture. Calendar of Events MEMORIAL SLOAN-KETTERING POST-TREATMENT RESOURCE PROGRAM Call 212.717.3527 to register for programs. SHARE (SELF-HELP FOR WOMEN WITH BREAST OR OVARIAN CANCER) 1501 Broadway, Suite 1720 NY, NY 10036 Call 212.719.0364 for further information. SHARE HOTLINE: Breast: 212.382.2111 Ovarian: 212.719.1204 ADELPHIA NY STATEWIDE BREAST CANCER HOTLINE & SUPPORT PROGRAM Adelphi University School of Social Work Garden City, NY 11530 Call 800.877.8077 for information about the Hotline and programs. JALBCA does not endorse the content or efficacy of any workshops or programs listed in the Calendar of Events; listings are for informational purposes only, so that our readership is aware of current offerings. |
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