Health
One-stop breast screening shop

By Beverly Creamer
Advertiser Staff Writer

Dr. Laura Hoque, medical director of the Kapi'olani Women's Center, points out a cancer spot on an X-ray of a female patients' breast tissue. A planned new center would focus exclusively on the diagnosis and treatment of breast care. Deborah Booker • The Honolulu Advertiser

While mammogram services in other parts of the country are being curtailed or stretched thin because of low insurance reimbursements, the Kapi'olani Women's Health Center envisions a major expansion over the next two years, with the goal of offering everything from mammograms, biopsies and surgery to chemotherapy, nutrition education, social and psychological support services for women — and even men — with breast cancer, all in the same place. Only radiation treatment would be excluded.

"We have the vision of a one-stop shop," said Willow Morton, vice president for both Kapi'olani and Pali Momi medical centers. It would rival centers in large Mainland cities, she said.

Fragmented care

"Today breast cancer care is extremely fragmented, and it's like that for most cancers," said Dr. Laura Hoque, medical director of the Kapi'olani Women's Center and the only surgeon in Hawai'i with a specialty in breast cancer.

Morton said that the baby boomer bulge in the population is entering those years when cancer risks increase, and the center would be designed to respond in a comprehensive and compassionate way to a traumatic moment in a woman's life.

Now, Hoque said, the patient herself is left to do all the legwork after diagnosis: find an oncologist, hunt up a surgeon, gather records, X-rays and test results and perhaps research treatment options. "It's all left up to the patient," she said.

'Unnecessary level of stress'

Independently of the Kapi'olani efforts, a Governor's Blue Ribbon Cancer Task Force is looking at ways to improve cancer care here, including exploring the feasibility of a stand-alone treatment center.

While individual medical centers here provide highly rated services and there is already considerable equipment sharing now, it's still incumbent on patients to find their way from one facility to another in pursuit of treatment options. That's hard at the best of times, but when a patient is facing a life-threatening diagnosis, it adds an unnecessary level of stress, say those who have faced the disease.

"This is the scenario that gets repeated in so many ways: 'I went to my physician who referred me to a surgeon who did the biopsy and later I was referred for radiation down at Queen's,'" said Chris Pablo, co-chairman of the task force and himself a cancer survivor. He said the situation is exacerbated for those on the Neighbor Islands.

For the panel, "the question is, given the size of the community and the competition that's in place at different institutions, what is economically feasible?" Pablo said.

Mammogram reimbursement low

But with its ambitious plans on the drawing board, Kapi'olani also hopes that an up-to-date center linking patients to Mainland clinical trials would keep patients from looking elsewhere for care. "Patients leave here saying they want something on the cutting edge," Hoque said. "But we can do this."

At the moment, said Hoque, Hawai'i clinics can't reliably match patients with the latest clinical trials because the Cancer Research Center of Hawai'i, which would be the logical linking point, does not provide patient care. Their focus is strictly research.

"There are hundreds of breast cancer studies ongoing that patients can be enrolled in but a lot require an in-patient center," Hoque said.

The Kapi'olani planners also believe there is also room to expand the reach of mammography here. Only about 60 percent of the women who should receive regular mammograms are actually getting them, Hoque said. The most recent American Cancer Society guidelines suggest women should have annual mammograms starting at age 40 because tumor grows more rapidly in younger women and changes more readily from lower- to higher-grade malignancy.

About 1,000 breast cancers a year are diagnosed in Hawai'i — meaning cancers are found in three to five of every 1,000 women screened. Kapi'olani now screens about 25 percent of Hawai'i women who get mammograms; the goal is push its share to 50 percent and beyond. The Women's Center does 60 mammograms a day, about 18,000 breast cancer screening tests a year, and expects to add two machines to the three in service now.

Snagging a big enough share of the market could be profitable, even though insurance reimbursements for mammograms are low across the country. Screening mammograms typically cost between $75 and $150, while diagnostic mammograms, performed when a problem is suspected, cost well over $200.

Recommended Medicare reimbursement rates, set by Congress, are substantially below that: $69 for a screening mammogram and about $83 for a diagnostic exam. Private insurance carriers use Medicare rates as one of the main guidelines in setting their reimbursement rates.

Experts say an aggressively marketed mammography program can benefit the community and a medical center with a "halo effect," identifying more cancers earlier in the disease process, and thus creating the need for further services. Mammograms become, in essence, a "loss leader," that pulls patients into the center. In the first year after expansion, Women's Center officials hope to perform 27,000 breast cancer screening tests. The second year would add another 5,000. "Once you're touched by it, you realize it's a lifelong disease," Hoque said. "You're seeing that doctor every month or couple of months."

The hospital is looking for a location, either an existing building near the Kapi'olani facility, or land on which a four- or five-story building can be built. While the board has not yet given final approval to the plan, the cost is expected to be $18 million, of which $8 million would be raised through a community campaign.

Meanwhile, Hoque said that the Women's Center is starting to expand its range of breast cancer services now. As soon as a new radiologist who specializes in breast care can be hired, Hoque hopes to begin a study of breast cancer diagnosis by ultrasound, which may have a higher tumor "catch" rate.