Rectal cancer patients without insurance or covered by Medicaid are almost twice as likely to die within five years as those privately insured.

Not only are they diagnosed at a later stage, but fewer receive recommended treatments at every stage.

More than half of the difference between patients with private insurance and those without was due to differences in how early they were diagnosed and whether or not they got standard treatment.

Researchers looked at information from the National Cancer Data Base, a national hospital-based cancer registry, to study insurance and other factors related to survival among 19,154 rectal cancer patients aged 18 to 64 years old.

They analyzed the impact of  insurance, age, sex, race and ethnicity, neighborhood education and income levels, cancer treatment facility type, stage, pathology features, and treatment on survival at five years.

Rectal cancer patients were diagnosed between 1998 and 2002, and their progress was followed until 2007.

Results

• Uninsured patients were diagnosed at Stage I (17.6 percent) less often than those with private insurance (31 percent).
• Uninsured were diagnosed at late Stage IV (22.5 percent) more often than privately insured (13.8 percent).
• Uninsured were twice as likely not to have a high school diploma (38.9% versus 19.9%) and be poor (44.8 percent vs. 24.1%).
• Patients with private insurance were more likely to be treated in comprehensive community cancer centers, while patients with no insurance were more likely to be treated in teaching/research hospitals.

Differences in standard treatment

• Stage I:  95.1 percent of private patients had surgery with or without chemo/radiation  compared to  83.4 percent of uninsured.
• Stage II:  91.4 percent of privately insured had recommended surgery with or without chemo/radiation while 79.4 percent of uninsured did.   7.7 percent of private patients had chemo/radiation but no surgery compared to 19.2 percent of uninsured.
• Stage III:  4.7 percent of private patients had chemo/radiation without surgery while twice as many (9.6 percent) of uninsured patients received this substandard treatment.
• Stage IV:  More than 3 times as many uninsured patients (14.8 percent) had no treatment at all compared to 4.4 percent of those with insurance.  Again, uninsured patients got less surgery (42.2 percent) than those with insurance coverage (60 percent).

Writing in an early online edition of Cancer, Anthony S. Robbins, MD, PhD and his team in the Department of Surveillance and Health Policy Research at the American Cancer Society said,

Our main finding that most of the excess mortality seen among Medicaid-insured and uninsured patients was explained by 2 modifiable factors (stage and treatment) suggests that improving insurance coverage and reducing cost-related barriers to primary care, CRC screening, and high-quality treatment would have a major impact on CRC survival disparities.

SOURCE: Robbins et al., Insurance status and survival disparities among nonelderly rectal cancer patients in the National Cancer Data Base, Cancer, Early View, June 2010.

According to new American Cancer Society statistics for 2010, 142,570 people will hear the difficult words, “You have colorectal cancer”, down from 146,970 in 2009.

Still, 51,370 families will get painful news when loved ones die from colorectal cancer.

Continuing this year, African Americans are more likely to develop colorectal cancer than whites and other races, to die of it, and to have poorer survival at every stage of the disease.

Each year the American Cancer Society estimates the number of new cases and deaths from cancer expected in the United States in that year.  They study trends in cancer rates and look at the impact of various types of cancer.

In 2010 colorectal cancer will again be the third most commonly diagnosed cancer in men and women and the second most common cause of cancer death.

2010 Colon and Rectal Cancer

Incidence

• In 2010, 102,900 new cases of colon cancer and 39,670 cases of rectal cancer will be diagnosed for a total of 142,570.
• This is a reduction of 4,400 new cases over last year’s estimate of 146,970.
• 72,090 men will be diagnosed with colorectal cancer (9 percent of all cancers) and 70,480 women (10 percent of the total).
• Incidence rates are projected at 59.0 per 100,000 men and 43.6 per 100,000 women – a decrease from 61.2 for men and 44.8 for women in 2009.
• Over a lifetime, 1 in 19 men and 1 in 20 women will develop colon or rectal cancer.

Deaths

Although the number of deaths from colorectal cancer are expected to increase in 2010, rates for both new cases and deaths continue to go down. As the American population grows and ages, more people are vulnerable to colorectal cancer.

• 51,370 deaths from colorectal cancer are expected in 2010, up 1,450 from 49,920 in 2009.
• 26,580 men and 24,790 women will die.
• After all cancer rates peaked for men in 1990, colorectal cancer death rates dropped by 10.27  per 100,000 men from 30.77  to 20.51, accounting for a third of the decrease in all cancers.
• For women, cancer rates peaked in 1991.  Since then women’s colorectal cancer death rates have dropped from 20.30 to 14.53, accounting for about 30 percent of the overall cancer death rate decrease.

Five year survival

• In the years between 1975 and 1977, just over half of people with colorectal cancer lived five years past diagnosis (52 percent).
• By 1999 through 2005, two out of three would live those five years (66 percent).

African American Disparities

Incidence Rates Per 100,000 by Race and Ethnicity

Five-Year Survival Percentages by Race

2010 Overall Cancer Burden

• 1,529,560 new cases of cancer are expected in 2010.
• 569,490 people will die of cancer.
• Incidence rates (rates per 100,000 people) have been going down 1.3 percent each year for men in the years 2000 through 2006.
• For women, incidence decreased by 0.5 percent each year from 1998 through 2006.

Although the rates of new cancers and cancer deaths are going down, cancer remains the leading killer of people under the age of 85 in the United States.

One in four deaths is due to cancer.

In 2010, 1,529,560 people will be diagnosed with cancer and 569,490 will die.

In reporting cancers statistics for 2010, the ACS team wrote,

Although progress has been made in reducing incidence and mortality rates and improving survival, cancer still accounts for more deaths than heart disease in persons younger than 85 years. Further progress can be accelerated by applying existing cancer control knowledge across all segments of the population and by supporting new discoveries in cancer prevention, early detection, and treatment.

SOURCE: Jemal et al., Cancer Statistics, 2010, CA: A Cancer Journal for Clinicians, published online July 7, 2010.

For comparisons to 2009, see Jemal et al., Cancer Statistics 2009, CA: A Cancer Journal for Clinicians, Volume 59, Number 4, July/August 2009.

Image: Figure #3: Jemal, Cancer Statistics 2009,  CA Cancer J Clin 2010, online July 7, 2010.

Whether this is because of different biology or lack of access to high-quality medical care has long been debated.

In a new study, blacks had very similar rates of polyps found during a screening flexible sigmoidoscopy.  But they were less likely to get a recommended follow-up colonoscopy.

While about 1 in 4 people had polyps discovered during their sigmoidoscopy, nearly identical percentages for blacks and whites, blacks got colonoscopy follow-up about 12 percent less often than whites.

For those who did get a colonoscopy, adenomas and advanced adenomas were just as likely in whites and blacks, as was the rate of cancers discovered.

The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial screened 60,572 people for colorectal cancer using flexible sigmoidoscopy.  Doctors recommended those who had abnormalities discovered during the screening test have a colonoscopy.  However, the trial did not pay for the follow-up exam.

Analysis of the PLCO trial found,

• 23.9 percent of whites had abnormalities found during flexible sigmoidoscopy compared to 25.5 percent of blacks, which was an insignificant difference.
• 72.4 percent of whites got a diagnostic colonoscopy compared to 62.6 percent of blacks
• During colonoscopy, 23.1 percent of blacks and 22.5 percent of whites had an advanced adenoma found.
• Nearly identical percentages had cancer discovered (2.1 percent of blacks and 1.5 percent of whites).
• Advanced adenomas were more frequently found on the right side of the colon in blacks (8.5 percent) than in whites (5.5 percent) suggesting that full colonoscopy that reaches the right side of the colon may be particularly important in screening African Americans.

Lead author Adeyinka O. Laiyemo, MD, MPH, from Howard University School of Medicine, and colleagues concluded,

We observed a lower follow-up for screen-detected abnormalities among blacks when compared with whites but little difference in the yield of colorectal neoplasia. Health-care utilization may be playing more of a role in colorectal cancer racial disparity than biology.

The study did not look at reasons that African Americans were less likely to get follow-up colonoscopies.  However, in an editorial accompanying the study results in the Journal of the National Cancer Institute, John Z. Ayanian, MD, MPP, from the Department of Health Care Policy discussed some potential barriers to follow-up care.

He pointed out that other research has shown:

• Blacks are less likely to have a primary care physician.
• They live more often in low-income communities with limited access to gastroenterologists.
• They may lack insurance that covers colonoscopy.
• They may not be able to afford out-of-pocket costs for colonoscopy not covered by insurance.

The barriers concerned Dr. Ayanian, who wrote,

These gaps in follow-up care were particularly concerning because up to one-quarter of participants who did not undergo colonoscopy were likely to have advanced adenomas that were neither detected nor removed. Valuable opportunities to prevent colorectal cancer were thus lost in these patients.

He called for programs like that in New York City which increased colonoscopy screening rates for black adults from 35 percent to 64 percent in four years to be expanded to other communities.  The program in New York uses public education, improved tracking systems, and patient navigators to get low-income people to screening.  He also cited the expanded Centers for Disease Control and Prevention program that will promote colorectal cancer screening for low-income Americans in 22 states and four tribal organizations.

He said,

Colorectal cancer is one important disease in which racial and socioeconomic disparities in outcomes can most readily be eliminated by ensuring that all eligible adults are effectively screened and abnormal findings are fully treated.

SOURCES:

Laiyemo et al., Journal of the National Cancer Institute, Advance Access, March 31, 2010.

John Z. Ayanian, Racial Disparities in Outcomes of Colorectal Cancer Screening: Biology or Barriers to Optimal Care?, Journal of the National Cancer Institute, Advance Access, March 31, 2010.

If you can’t have a loved one with you during a painful procedure, just looking at your partner’s picture may make it hurt less.

The American Society for Radiation Oncology has a new website for patients, and open enrollment for Medicare plan coverage begins on November 15 and extends through the end of the year.

Research News

• African Americans were more likely to die of colorectal cancer in a study of over 13,000 patients.  They were more likely to have stage IV disease when diagnosed and less likely to have surgery.   But after late stage and lack of surgery were taken into account, racial differences in survival disappeared.  Writing in the November 2009 issue of the Journal of the American College of Surgeons, Dr. Timothy L. Fitzgerald and team said, “These data suggest that improvements in screening and rates of operation may reduce differences in colorectal cancer outcomes between African-American and Caucasian patients.”
• Canadian women were more likely than men to be diagnosed with an early colorectal cancer in the three years after a negative colonoscopy.  Researchers in Manitoba studied billing records for nearly 46,000 patients who had a clear colonoscopy and found that women with a negative colonoscopy were about as likely as women in the general population to develop colon cancer during the first three years after their test.  Then their risk dropped to about 40 to 50 percent lower.  The men’s  risk was 40 to 50 percent lower throughout the follow-up period.  Older women and those whose colonoscopy wasn’t done by a gastroenterologist were the most likely to have a missed or early colorectal cancer.   Harminder Singh MD, MPH and his team at the University of Manitoba reported their results in the American Journal of Gastroenterology online November 10, 2009.
• Looking at the picture of a loved one or holding your boyfriend’s hand reduces painful feelings, according to a study done by psychologists at UCLA. Women reported less pain when heat was applied to their forearm if they were holding their partner’s hand rather than a stranger’s hand or a ball during the experiment.  Just looking at a picture of their loved one also reduced the amount of pain they said they had.  Sarah Master PhD led the study.

Other Headlines

• The American Society for Radiation Oncology (ASTRO) has launched a newly designed patient website RT Answers. The new site is easier to navigate and includes more pictures.  The front page helps patients search for a radiation oncologist and provides a gateway to treatment information.
• Medicare beneficiaries can make new coverage choices during the annual open enrollment period from November 15 through December 31.   Online comparisons of original Medicare, Medicare Advantage, and supplemental Medigap policies are available from CMS.  Also changes in Part D Prescription Drug coverage plans can be made during open enrollment.

Surgical robots are being developed with a light touch that can tell the difference between normal and tumor tissue.

Research Reports

• About 12 percent of stage I and II colon cancer patients in a German study had one or more clinical characteristics that increased their risk of dying from their cancer.  Overall, cancer-specific survival for the group was 94.8 percent at 5 years and 91 percent at ten years.  However, invasion of lymphatic vessels, poor tumor grade, or length of tumor greater than 6 centimeters reduced survival.  With one poor characteristic, five and ten year cancer-specific survival was 94.8 percent and 88.9 percent.  With all three, survival fell to 87.5 percent at 5 years and 72.9 percent at ten years.  Patients with none of the characteristics had a five year survival of 96 percent.  None of the patients in the study had chemotherapy after their surgery. The study of a prospective Munich database was reported by surgeon Ralf Gertler in the European Journal of Cancer online August 19, 2009.
• Colorectal and breast cancer patients of any race who are treated in hospitals where more than half of patients are black have higher death rates.  For colorectal cancer, the increased risk was almost 30 percent even after adjusting for other risks like age, stage, race, and socioeconomic factors.  “Efforts aimed at increasing early detection through screening and decreasing incidence with preventative services are essential for decreasing racial disparities in mortality, but where a patient receives care after a cancer diagnosis may be equally important,” senior study author Arden M. Morris, MD, MPH said.  The study was published in the July 20, 2009 issue of the Journal of Oncology.
• Acupressure wristbands reduced nausea from radiation therapy.  However, there was no additional effectiveness if patients were given information before using the bands that led them to expect results. Joseph Roscoe, PhD, and his colleagues at the University of Rochester reported their on their study in the Journal of Symptom and Pain Management online March 31, 2009.
• Researchers in Japan found no connection between how much fish an individual eats and colorectal cancer.  Following nearly 40,000 people for 9 years, the scientists found 566 cases of colorectal cancer but no difference in risk between those who ate the most fish and those who ate the least. Y. Sugawara reports study results in the British Journal of Cancer on August 25, 2009.

Other Headlines

• Robots may have a lighter — and better — touch than surgeons.  Tumors usually feel stiffer than surrounding tissue, and in open surgeries, doctors put light pressure on organs to identify areas with potential cancer.  With minimally invasive (laparoscopic) surgery, they cannot feel tissue.  A new robotic system is being developed to replace the surgeon’s hand, systematically putting light pressure on organs to locate tumors.  The robots use less pressure and use it consistently.  Medical News Today on August 22 had an article about the Canadian CSTAR project that is developing the robots.

Risk of dying during that first year was 50 to 90 percent higher among the uninsured.  They were more likely to diagnosed at an advanced stage and live in poor neighborhoods.

Other illness (comorbidities) was lowest in privately insured patients and highest in patients under 65 on Medicare, who were likely to have Medicare because of a disability.

Trying to track down reasons for why uninsured colorectal cancer patients have poorer survival, researchers at the American Cancer Society in Atlanta analyzed information for nearly 65,000 patients with colorectal cancer in the National Cancer Data Base in years 2003 through 2005.  In addition to cancer information, they studied comorbidities to see if they were contributing to increased deaths.

After adjusting statistics for factors known to affect survival including age, stage at diagnosis, where patients were treated, and neighborhood education level and income, risk of dying was significantly higher for all patients without private insurance—78% higher for uninsured patients, 64% higher for those insured by Medicaid, and 86% higher for those insured by Medicare.

However, although patients who were uninsured or who had Medicaid or Medicare had more comorbidities than patients with private insurance, that difference didn’t have an impact once insurance status was figured in.

Anthony S. Robbins, MD, PhD and his colleagues in the Department of Surveillance and Health Policy Research at theAmerican Cancer Society in  Atlanta concluded,

Thus, using data from more than 64,000 colorectal cancer patients in a large national database, we found substantial differences in comorbidity level by insurance status, but these differences did not explain the poorer survival of patients without private insurance. Even after adjustment for age, stage, facility type, neighborhood education level and income, and number of comorbid conditions, whites and blacks without private insurance had 40% to 80% higher risk of death during the first year after diagnosis. These higher death rates translated into large reductions in 1-year survival for patients without private insurance and those with higher comorbidity levels.

SOURCE: Robbins et al.,Journal of Clinical Oncology,Volume 27, Number 22, August 1, 2009.

After looking at factors including poverty, stage at diagnosis, and treatment received, researchers in Detroit found the differences between races disappeared.

The research team from the Barbara Ann Karmanos Cancer Institute in Detroit, Michigan studied over 9,000 colorectal cancer patients in the Detroit metropolitan area and analyzed socioeconomic, demographic, and treatment information about them.

Socioeconomic information (SES) was determined by census tract looking at poverty, occupations, and educational levels within the tract.  Surveillance, Epidemiology and End Results (SEER) cancer statistics were used for sex, age, treatment information, and survival.

African Americans were more likely to be diagnosed at advanced stage IV and live in a poor census tract.  They had poorer survival than whites.

However, once socioeconomic, clinical, and demographic information was taken into account, survival differences no longer existed.

Writing in Cancer, Ben Yan, M.D., concluded,

Racial disparities in colorectal cancer survival dissipate after adjusting for other demographic and clinical factors. These results can potentially affect medical guidelines regarding screening and treatment, and possibly influence public health policies that can have a positive impact on equalizing racial differences in access to care.

SOURCE: Yan et al., Racial differences in colorectal cancer survival in the Detroit Metropolitan area, Cancer, Early View, July 13, 2008.

No matter where they lived, incidence of colorectal cancer dropped significantly between 1995 and 2004 for white Americans aged 65 and over, most of whom have Medicare that covers colonoscopy screening.  However, colorectal cancer rates for whites from 50 to 64 did not fall if they lived in rural areas or counties where there was poverty, lack of insurance, or few primary care providers.

African Americans only benefited from reduced incidence if they were over 64 and living in an affluent community.

Researchers from the American Cancer Society in Atlanta reviewed colorectal cancer incidence rates in metropolitan and rural counties across the United States looking at poverty, age, race, and ethnicity. They also measured access to health care by the supply of primary care physicians and amount of insurance coverage.

Medicare made a difference for older people.  Colorectal cancer fell for whites over 64 in all areas, including those with poverty or few primary care physicians.  However, for Hispanics and African Americans eligible for Medicare, only those living in more affluent counties without poverty and with a good supply of primary care saw colorectal cancer rates decrease.

For younger whites from 50 to 64, not covered by Medicare, rates did not decrease if they lived in a county with high poverty, many uninsured, lack of primary care physicians, or in a rural area.

Hispanics and African Americans under 65 saw no reduction in incidence rates in general, no matter where they lived.  If they were 65, rates did not decrease in counties with poverty, lack of insurance, and few primary care physicians.  African Americans also did worse in rural communities.

Colonoscopy screening increased significantly for whites in both age groups.  However, screening with colonoscopy didn’t improve for Hispanics below Medicare age at all, nor for Hispanics over 64 who lived in areas with high poverty.

Likewise African Americans from 50 to 64 saw no increase in colonoscopies if they lived where there were high rates of uninsured.  Colonoscopy screening for African Americans old enough for Medicare didn’t improve where there was poverty or a poor supply of primary care physicians.

Writing in Cancer Causes and Control, Yong Ping Hao and colleagues concluded,

Individuals residing in poorer communities with lower access to medical care have not experienced the reduction in colorectal cancer incidence rates that have benefited more affluent communities, and that this is likely explained in part by lower utilization of colorectal endoscopic screening even in older populations with coverage through Medicare. Further research is needed on factors that explain the disparities and potential interventions to address them.

In other headlines, colorectal cancer screening for the uninsured will begin on July 1 in Minnesota, and if screening reveals cancer, treatment will be covered under the Minnesota Medical Assistance program.  The FDA warned consumers not to use Zicam nasal gel or swabs to avoid loss of smell, and doctors advised patients on long-term Xeloda therapy to carry a letter from their oncologist explaining possible loss of fingerprints if they travel internationally.

Research Reports

• Communities with large percentages of African Americans have less access to the doctors critical to colon and rectal cancer care. Analyzing data from the HHS Area Resource File, researchers discovered that as the percentage of African Americans in individual US counties increases, the numbers of gastroenterologists, radiation oncologists, and colorectal cancer surgeons decreases.  Awori J. Hayanga, MD wrote in the June 2009 Archives of Surgery, “Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.”
• Measuring health-related quality of life, older adults with most cancers, except melanoma and endometrial cancer, have poorer physical health than matched over 65 controls.  However, only older cancer patients with lung, colorectal, and prostate cancer had significant reductions in mental health.  Bruce Reeve and his team linked data from the Medicare Health Outcomes Survey (MHOS) and NCI SEER cancer registry to determine how a cancer diagnosis affects both physical and mental health and quality of life. They reported their results online June 9, 2009 in the Journal of the National Cancer Institute. A JNCI Memo to the Media has more information about the study.
• Palliative sedation given to manage severe symptoms at the end of life does not reduce survival time when compared to patients treated with standard hospice protocols, according to a study in the July Annals of Oncology. The study resolves some ethical questions of using sedation for unmanageble end-of-life pain even if it might hasten death.  Dr. M. Martoni wrote, “Palliative sedation therapy does not shorten life when used to relieve refractory symptoms and does not need the doctrine of double effect to justify its use from an ethical point of view.”

Other Headlines

• On July 1, 2009, with funds from an increased tobacco tax, the Minnesota Colorectal Cancer Prevention Act will provide screening for uninsured and underinsured residents of Minnesota. Program participants must have family incomes less than 250 percent of poverty and be over 50 or at high risk of colon cancer.  If cancer is found during screening, patients will be covered by Medical Assistance for their treatment. The American Cancer Society recognized state representative Maria Ruud, a nurse practitioner, as Legislator of the Year for her leadership in writing the legislation and getting it passed.
• On June 16, 2009 the FDA warned consumers to stop using and throw away intranasal Zicam Cold Remedy Nasal Gel and Zicam Cold Remedy Swabs. The zinc-containing  products have been linked to a loss of the sense of smell, for many people with the first use.  Zicam Cold Remedy Swabs, Kid Size has been discontinued, but the FDA is concerned that some people may still have it in their homes.  Because children may not report loss of a sense of smell, the FDA is particularly concerned with the use of zinc in the noses of children.  The FDA has sent a warning letter to Matrixx Initiatives telling them that these products cannot be marketed without FDA approval.
• Hand-foot syndrome side effects from Xeloda® (capecitabine) may cause loss of fingerprints with long-term use.  The July 2009 Annals of Oncology reports on a case of a man with head and neck cancer who took oral Xeloda for over three years as maintenance therapy.  He was detained trying to enter the United States because his fingerprints could not be detected.  In a letter to the editor of Annals, doctors say that patients on long-term capecitabine therapy should be warned about the possibility of fingerprint loss and carry a letter from their oncologist explaining the situation.  They point out that it is unclear how soon fingerprint loss may occur.

In other headlines, both patients and doctors liked virtual, computer videoconferencing visits, and the FDA reports that shortages of fentanyl patches have been resolved.

Research Reports

• Finding cancer at a late stage is more common in Illinois cities than in rural areas. Colorectal, breast, prostate, and lung cancers — are more common in the most densely populated areas of Chicago and follow a pattern of reduced risk as the area population decreases. There was a small increased risk in the most remote rural areas. Researchers used data from Illinois State Cancer Registry from 1998 through 2002. Even after accounting for socioeconomic differences and access to nearby health care facilities, the disparities between city and rural remained. Writing in the early view edition of Cancer published May 11, 2009, geographer Sara McLafferty, Ph.D. said, “The observed pattern of urban disadvantage emphasized the need for more extensive urban-based cancer screening and education programs.”
• Telephone calls and personally tailored printed diet and exercise information reduced the rate of functional decline in older, overweight long-term cancer survivors.  They lost weight and their physical activity, diet, and quality of life improved.  At the beginning of the year-long program both the group in the program and a control group had functional abilities averaging 75.7 on a 100 point scale.  During the year, overall scores declined 2.15 points for survivors in the program compared to a 4.84 loss for the control group.  Leg strength increased,while the control group’s leg function declined further. Program participants were over 65 and had survived cancer for more than five years. Miriam C. Morey, Ph.D. at Duke University reported the results of the study in the May 13, 2009 Journal of the American Medical Association.
• The caregivers of cancer patients show very real changes over time in blood markers of inflammation — both those that promote inflammatory changes and those that protect against it.   Family members caring for patients with a very aggressive form of brain cancer had blood and saliva tested.  A matched group of controls, similar in age and background but free of major life stresses, were also tested.   Psychological tests showed the caregivers were more stressed than the average population and had more depression.  Excess inflammatory response left them vulnerable to heart disease and other illnesses that are triggered by chronic inflammation.  Nicolas Rohleder and  his team from the University of British Columbia published their work in an early online edition of the Journal of Clinical Oncology on May 11, 2009.

Other Headlines

• Virtual visits with a doctor rated well with both patients and doctors.  Patients found talking with a doctor via desktop videoconferencing satisfactory in the time spent with the doctor, personal aspects, and ease of the interaction.  Patients in a study conducted at the Massachusetts General Hospital saw two different doctors, one via teleconferencing and one face-to-face.  They had similar evaluations for both encounters.  Another group saw two different doctors face-to-face without use of telemedicine.  The two doctors agreed on diagnosis 84 percent of the time in the first group, using both teleconferencing and face-to-face visits and 80 percent of the time when they both saw the patient only in their office.   Doctors Ronald Dixon and James Stahl wrote about their study in the Journal of Telemedicine and Telecare.
• The FDA  has announced that the shortage of fentanyl patches has been resolved and that the market is being supplied by five different firms.