By Beth D'addono
When it comes to health, women and men are definitely not created equal.
Besides the obvious gender-specific conditions such as pregnancy and menopause, women’s physiology and psychology come into play, affecting everything from how often they access health care for themselves to the symptoms they present for a heart attack. Add the possibility of gender bias on the treatment side, and women face a unique set of challenges.
Mirroring grim numbers in other states, heart disease is the leading killer of women in New Jersey, followed by cancer, stroke, injuries and suicide. The New Jersey Office on Women’s Health has identified cardiovascular disease and cancer as two of the state’s major public health concerns.
It’s clear that education is key — witness the plethora of pink ribbons that raise awareness about the treatment and prevention of breast cancer. But beyond the ribbons, where exactly do women stand when it comes to the treatment of the diseases that most impact their quality of life?
Here is a look at the top health challenges facing women and what New Jersey physicians are doing to improve treatment.
When the American Heart Association held its annual meeting in Orlando in November, Marc Klapholz, director of the Division of Cardiology at the University of Medicine and Dentistry of New Jersey, was thinking about women and heart attacks.
Klapholz was presenting a paper about the disparity in how women and men are treated when they exhibit symptoms of a myocardial infarction — a k a heart attack.
“Despite the fact that cardiovascular disease is the leading killer of women over age 25, women’s symptoms aren’t taken as seriously,” he says. When it comes to “door-to-balloon” time (the period between when the patient enters the ER to when he or she is whisked off to surgery in the catheterization laboratory) it takes longer for women to be treated than men.
“And that door-to-balloon time correlates directly to survival. The preconceived idea is that heart attacks are for men.”
Klapholz sees two populations contributing to this dangerous trend. First, he faults health care providers. Women, he says, show atypical symptoms. “Beyond the usual chest, arm and jaw pain, they may have nausea, abdominal discomfort, and edema. It’s up to us to be sensitive to this and not to miss anything. We can’t let the unproven notion that estrogen protects women from heart disease influence our diagnosis.”
The other issue is more cultural. “Women are the caregivers. They don’t have people watching them the way they watch their spouse and children. There’s a price paid for that.”
One of the ways Klapholz works to eliminate gender bias in the treatment of heart attacks is to reduce the door-to-balloon time in all his patients across the board.
In 2007, University Hospital in Newark instituted a system that wirelessly transmits EKG results directly to the cardiologist’s smartphone. “We can read the results and call the EMS with our decision before they even get in the ER door. With that system in place, we’ve normalized the door-to balloon time in men and women.” And the magnitude of improvement in women happens to be better than in men.
His advice to women? “Talk to your doctor about heart disease and symptoms of heart attack. Don’t wait for your doctor to bring it up. You start the conversation.”
Every day in her practice at University Hospital, Lillian Pliner sees the ravaging effects of a disease that kills more women than breast, ovarian and uterine cancers combined. And while there are cases of women with no history of smoking getting lung cancer, more often cigarettes play a role.
Despite this, one out of four women still smokes, says Pliner, an assistant professor of medicine in the division of Hematology/Oncology at New Jersey Medical School.
“In terms of biological and genetic issues, it seems that women may have genes that make them more vulnerable to the harmful effects of cigarette smoke,” says Pliner. “Women smokers run a higher risk of developing lung cancer than their male counterparts who smoke. They seem more prone to the addiction and have a harder time quitting than men.”
Secondhand smoke also can play a deadly role in a woman’s health profile. “I have to ask carefully about a patient’s background. Is she married to a smoker? Did she grow up in a house full of smoke? Work in a bar or place where people smoke?” says Pliner. And while lung screening hasn’t proven as effective a cancer indicator for women as the pap smear or mammogram, it’s still the best available diagnostic tool.
“Most of my patients are from the inner city. I see a lot of people who have neglected themselves, who don’t go for regular checkups. Even if women just go to their OB/GYN, there’s a health professional taking a look at them and asking them questions. They can get referred to the right place from there,” says Pliner.
Women also tend to minimize or ignore their own symptoms, she says. “Women are busy working and caring for children and aging parents. But they can’t leave themselves out of the equation.” A chronic cough, pain in the ribs and chest, unexplained weight loss and coughing up blood are all reasons to get checked.
One impetus for women with symptoms to get help is that those who undergo lung cancer surgery are more likely to live longer than their male counterparts, even in the later stages of the disease. Women also tend to survive longer than males when treated with chemotherapy.
But while the new drug Erlotinib is showing some promise, the disease is still incurable. “We’re doing much better,” Pliner says. “More patients are living five years and beyond. But my hope is for better early-detection screening that would find tumors when they are still small. Then they can be surgically removed and we can use chemotherapy to prevent the cancer from coming back.”
For now, however, the best deterrents are regular checkups, avoiding smoking and paying attention to anything that seems abnormal.
The recommendation in November by the United States Preventive Services Task Force that only women ages 50 to 74 get routine mammograms reached the operating room where breast surgeon Diane Gillum was working.
“Everybody from patients to nurses and doctors were talking about it,” said the surgeon, who works in the Virtua health care system in Marlton. “It really gets to the meat of the issue of costs versus benefit in health care.”
While she doesn’t discount the stress caused by false positives, “we all know women who had their cancer diagnosed early from a mammogram. So I also don’t see us doing things differently in the near future.”
Tom Kearney, director of the Cancer Institute at New Jersey’s Breast Cancer Services and associate professor of surgery at Robert Wood Johnson University Hospital, says professionals in the field are still trying to come to a consensus as to who should get screened and how often, and who should get MRI screenings.
“One of the things that’s controversial right now is whether women who have increased risk should do something different than women who are at regular risk. Unfortunately, there’s not really been a good study that has been done,” he says. “A lot of women at my practice have little or no risk for breast cancer, but everybody wants an MRI. I spend a lot of time explaining to them that’s not going to change the outcome.”
In a state with one of the highest breast cancer rates in the nation, Gillum sees a few trends in her practice.
“Women are opting more for mastectomies, something I wouldn’t have predicted 10 years ago.” In some cases, she sees this among women who have cancer in one breast and decide to have the other breast removed prophylactically.
Kearney says preventive mastectomy has a limited role and is not for everyone. “I’ve noticed that if a celebrity that happens to have breast cancer had a double mastectomy, interest in that procedure kind of goes up for a while — ‘So and so had it, so why don’t I have this?’ ”
Gillum says that many women are rejecting lumpectomies in favor of more aggressive treatment.
“I think there are a few reasons for this,” she says. “First, technology is getting so good that we’re seeing even the slightest change in breast tissue, so there are more women being treated. And women who have experienced cancer once just don’t want to go through it again. Also, the reconstruction process is better than it’s ever been.”
While Gillum has seen strides in the area of education, the mystery remains why one woman gets breast cancer and another doesn’t.
“If you look across large groups of women, contributing reasons become apparent, from social issues to later childbearing and obesity as it relates to girls getting their periods earlier. These are tough issues to look at.”
On the positive side, survival rates are improving.
“We have made headway in the past five to nine years,” Gillum says. Increased awareness and the backlash against hormone replacement therapy are two factors, she says. Kearney says diagnosis and treatment for breast cancer have dramatically improved in the last decade.
“We have a number of tests available to help determine what types of treatment people require on a more individual basis,” he says. “Twenty years ago, everyone got a mastectomy and then some chemotherapy. Now there’s Herceptin; there are hormone blockers; there are different chemotherapy protocols. There are different programs you can use to predict people’s chance of recurrence.”
Gillum hopes for a screening test in the future that will identify women at greater risk. “The one size fits all just isn’t working … There will be a point in the not-so-distant future where we’ll be able to destroy the tumor inside the breast with a probe.”
Despite the doctor’s job description, a world without breast cancer surgery would be just fine with her.
Just the mention of ovarian cancer makes women queasy. Like pancreatic cancer, it’s one of the most deadly malignancies. Ovarian cancer can be asymptomatic, and because of this, it often isn’t diagnosed until an advanced stage. And it kills.
“The poster child is always Gilda Radner, but that’s not always the way the story goes,” says Randolph Deger, a gynecologic oncologist at Virtua. “Our survival rates are improving to the 5-to-10-year range, albeit with chemotherapy. But unfortunately, our cure rates are the same.”
Deger, who spends 90 percent of his time in clinical patient care, is cautiously excited about the new OVA1 Test, approved by the FDA last September. It is the first blood test that can help physicians determine whether a woman is at risk for ovarian cancer prior to biopsy or exploratory surgery.
“Of course we don’t want doctors to use this test in lieu of surgery or good clinical judgment,” says Deger. “A positive doesn’t guarantee there is cancer, but it does indicate a greater risk.”
There are a few ways women can increase that risk, including taking oral contraceptives, having children and gaining weight. Obesity is a factor in all kinds of health problems, from colon and ovarian cancer to diabetes.
In his 15 years of taking care of women with cancer, Deger found it invaluable to be board-certified in hospice and palliative care as well.
“You can’t just treat a woman for two years and then walk away at the end.”
At the same time, advances in chemotherapy have increased his patients’ quality of life. “That has also made it possible to use multiple secondary surgical procedures to remove cancer cells, something we never used to do unless it was an emergency.”
While ovarian cancer doesn’t always reveal itself, Deger urges women to pay attention to any unusual bloating, pelvic pressure, urinary or bowel symptoms they might have.
“Don’t pooh-pooh it as IBS (irritable bowel syndrome). If symptoms persist for a few months, have it investigated. We don’t want to miss an opportunity.” Brian Slomovitz, a gynecologist at Overlook Hospital and Carol G. Simon Cancer Center, says more than 200 to 300 biological therapies have become available through clinical trials for various cancers in the past five years.
Patients should not only try to get the best treatment possible, but consider participating in clinical trials, he says. “The old thought was that in order to get a good clinical trial, you need to go to an academic university, and that’s not true anymore. One of the advantages of being in North Jersey is that most of the pharmaceutical companies are here … and they really love keeping some of the trials in New Jersey.”
Additionally, Slomovitz says surgeries are now minimally invasive thanks to technical advances such as laparoscopic and robotic surgery. Whereas patients used to spend a week in the hospital for recovery, they can now go home after a couple of nights.
Vandana Singh, a rheumatologist at Morristown Memorial Hospital, has noticed that many of her female patients have been suffering hand arthritis, especially in their thumb joints. “Obviously, everyone uses their hands. It’s really interesting that I see the hand arthritis being really more a problem among females. I don’t know if it’s just the different types of activities that females do in terms of child care over the years, the laundry, the dishes and things like that.”
More women than men get their joints replaced. And thanks to a couple of smart companies, they can now opt for a gender-specific knee. “Forty years ago, there was just one-size knee,” says Rajesh Jain, an orthopedic surgeon who practices at Virtua Memorial Hospital in Mount Holly. “Then there was small, medium and large. Now, based on anatomical studies, a few companies have designed implants that fit women’s knees better.”
Besides being generally smaller, a woman’s femur is shaped slightly differently from a man’s. Before, surgeons would have to shave off precious bone to get a fit, or use an implant that would hang slightly over the edge of the bone, impacting soft tissue and creating problems with the way the patella tracked.
“We’ve been offering our patients the option about four years now, and while there is no long-term research evidence to say it’s a better system, I just think it makes sense.”
Joint replacement surgery is booming. “There are estimates that the 700,000-plus surgeries in 2005 will more than double by 2030 to around 4 million,” he says.
Joint replacement is happening at a younger age, fueled in part by Baby Boomers who consider 60 the new 40 and have no intention of giving up their active lifestyles.
“This used to be thought of as an operation for the elderly, somebody over 70 who couldn’t walk,” says Jain. “That’s shifted to the 45- to 50-year olds who want to maintain their quality of life. They may say, ‘I can live with this, but I can’t shoot hoops with my grandson or play tennis.’ ”
And while old-school joints used to last only 4 or 5 years, today’s hardware is pushing 15 and even 20. Knees and hips are the most successfully replaced joints, with ankles and shoulders close behind.
“When we get to the smaller joints like wrists, fingers and elbows, the longevity of our success rate starts to fall out,” says Jain. What he expects to see in his lifetime is an injectable material that repairs, or replaces, spent cartilage. “That way we could avoid joint replacements altogether.”
Until then, Jain sees his future including 300-plus surgeries a year, 60 percent of them on women. One disturbing trend, however, is that women tend to put off knee replacements longer than men, which can compromise their surgical results.
“I use this info not to tell women to hurry up and have surgery, but to consider it more strongly as conservative measures fail. We’re not quite sure yet as to why this difference seems to be there in women, but it is certainly important.”
Singh says Morristown Memorial Hospital and many other places offer inexpensive exercise classes that help prevent degenerative arthritis. Additionally, she highly recommends tai chi. “I think it would really help a variety of symptoms because tai chi is really a controlled stretching exercise,” she says. “I think the stronger your muscles are, the more stress would be taken off the joints. So I think it can only be beneficial.”
Office of Women’s Health,
New Jersey Department of Health and Senior Services
50 East State Street, Box 364
Trenton, NJ 08625-0364
E-mail: Peri L. Nearon, MPA. email@example.com
Martin Tsai contributed to this report
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