‘s Shots blog.

Bill Sneddon had a feeling he was in trouble when his doctor called with his latest test results.

“I just had a premonition that something’s not right,” said Sneddon, 68, of Ocean Township, N.J.

And, sure enough, Sneddon’s instincts were right. He had prostate cancer.

“Well, it’s an eye-opener, you know. I didn’t know if I had to buy a yard sale sign, you know,” he said. “It’s a shocking thing … It always happens to someone else.”

After getting over the shock, Sneddon, a retired police chief, quickly started investigating his options, including surgery and radiation. The next day, a golfing buddy told him about a new kind of radiation treatment for prostate cancer.

“He told me that I should look into proton therapy. And I’ve known him a long time, so when he told me this is a treatment I should get, I knew this is a treatment I better get,” Sneddon says.

So Sneddon was excited when he discovered that the  had recently opened in Somerset, N.J., about an hour and a half away from his house.

“It’s like coming to a health club or a five-star hotel,” Sneddon said recently as he waited for the next round of his nine weeks of treatment.

Sneddon looked more like he was at his country club than in the waiting room of a cancer clinic. The lobby has big windows, high ceilings, a rock wall surrounding a blazing fireplace. Relaxing music was playing.

But beyond the comfortable atmosphere, what really draws patients like Sneddon to proton therapy is how it works.

“It’s sort of like the difference between using a bullet, which passes through a person, and like a smart bomb that enters into a certain position, deposits its energy and then releases its radiation to that location,” says , a radiologist at ProCure who’s treating Sneddon.

Because proton therapy can be targeted much more precisely, it should minimize any damage to sensitive nerves and tissue around the prostate. The hope is that it translates into far fewer side effects, such as impotence and incontinence.

But proton therapy has become the center of an intense debate. Critics say it’s an example of a big problem with the U.S. health system: Doctors start using expensive new treatments before anyone knows whether they work, whether they’re safe, and whether they’re worth the extra money.

“There’s a concerning trend of us building new and expensive new technology and using it for a common cancer like prostate without proving, really, that it’s equivalent to the existing technology,” said  of the University of North Carolina at Chapel Hill.

“New treatments can — even though they’re promising — can potentially not be better and can even be worse,” Chen said. “I think we have to do careful studies before we adopt new treatments.”

The ProCure clinic is the newest of 10 proton centers around the country, and there are perhaps 10 more on the way. That has many experts worried.

“There’s no convincing evidence that it’s better. The jury really is out on this new technology,” says , a cancer radiologist at Harvard Medical School. “It might be better. I feel it’s probably the same. It might even be worse.”

And Zietman can’t help but worry about how much it costs: at least $50,000 for each patient, which is about double the price tag for regular radiation.

Here’s why: Those huge proton machines are incredibly expensive. They cost between $100 million and $200 million to build.

“There’s almost no other medical device … that I can think of that comes close to a proton treatment facility,” Zietman said.

Doctors developed proton therapy for tumors in really sensitive places, such as in the eye, on the spine or in a child’s brain.

But then Medicare started paying for it for prostate tumors — so more proton centers started promoting it for that.

“Any institution that forks out that kind of money and makes that kind of investment is obviously going to want to recoup that investment fairly rapidly,” Zietman said.

And new proton centers started opening up. All this means that the health care system is suddenly paying a lot more to treat prostate cancer with a therapy that so far doesn’t look significantly more effective than other options — and may be worse. In fact, Chen  the results of a study over the summer that suggested proton therapy might cause more side effects, such as bleeding from the bowel, pain and severe diarrhea.

“Unfortunately, this is like driving a Ferrari to the grocery store and asking your next-door neighbor to pay for the Ferrari,” said  of the Prostate Cancer Treatment Center in Seattle.

Now, proton therapy has lots of fans. In fact, doctors are presenting new studies at the ‘s annual meeting in Boston this week that they say show how well it works. They say data from thousands of men provide powerful evidence that the therapy is effective and safe.

“If cost were the same, there would be no debate about providing less radiation to a patient, which is always better,” said Leonard Arzt of the .

While the debate continues, men like Bill Sneddon are lining up to get it.

After changing into a hospital gown, Sneddon walked into a sleek, new treatment room. It’s very sci-fi-looking. No antiseptic smells.

Sneddon climbed onto a motorized platform and lay down in front of a big nozzle that was sticking out of the wall.

The nozzle is the business end of a gigantic machine down the hall: a 220-ton gizmo that was shipped over from Belgium. That huge linear accelerator shoots out the proton beams.

Glowing red laser lights criss-crossed Sneddon’s body. The technicians use the lasers, X-rays and three little gold pellets that Tsai injected around Sneddon’s prostate gland to make sure he’s positioned just right. The key is to make sure the proton beam zaps his prostate gland and, hopefully, nothing else.

“There’s absolutely no sound that’s emitted from the proton machine. There’s no sensation on the skin to indicate that the treatment is being received,” Sneddon said during the treatment.

In less than a minute, he was done.

“I’ve had a couple days where I very easily could have fallen asleep through the whole procedure,” said Sneddon, who so far said he feels great, with no signs of any side effects.

Sneddon figures it’s the insurance companies who are behind all the questions about proton therapy. Medicare and his private insurance are covering his bills — he doesn’t even know how much it costs.

So he’s even urging a friend who just found out he has prostate cancer to check out ProCure.

In the meantime, a big, carefully designed study is just getting going to try to settle the issue. But the results won’t be ready for years.

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This story comes from our partner ‘s Shots blog.

Amber Cooper and her husband were doing OK. They both had jobs. A healthy 5-year-old son, a house in Riverbank, Calif., and health insurance from her job in the accounting department of a small manufacturing company.

Amber Cooper lives in Modesto, Calif., with her 5-year-old son, Jaden, and her husband, Kevin. She had a liver transplant when she was 10 years old and has to take anti-rejection medication. (Photo by Deanne Fitzmaurice for NPR)

But then one day everything changed.

“We were in a conference room getting the information and I had heard rumors but didn’t know if it was true and started crying in front of everyone and actually had to excuse myself to gather myself together and go back in. It was devastating for me,” said Cooper.

It was devastating because the rumors — her worst fears — had come true. Cooper had a liver transplant when she was 10. So she takes a drug twice a day so her body won’t reject her liver. She was in that conference room for a meeting about her health insurance.

“Every year my company changes the insurance. And instead of giving us three different choices for insurance plans they were changing to one, which was a high-deductible plan with no prescription coverage,” she said.

Cooper was stunned. Her anti-rejection medicine costs way more than she could afford on her own — more than $1,000 a month.

Cooper, 30, started a frantic search for help. Finally, she found the , which was willing to pay for her medication. But she still couldn’t afford the $300 blood test she needs every month to make sure she’s not rejecting her liver.

“It is scary because the only way to tell if you’re going to go into rejection is by the blood work. Your numbers will be a little bit crazy and then the doctors will be like, ‘OK, you need to get in and we need to check you out and make sure you’re OK.’ So I really took a risk not getting that blood work done. But I couldn’t afford to get it done. I really couldn’t,” she said.

What happened to Cooper is happening more and more these days.

“Beneath the surface what health insurance is in the country has been changing really dramatically. And just in plain language it’s becoming skimpier and skimpier and less and less comprehensive,” said Drew Altman of the Kaiser Family Foundation, a private, non-profit, non-partisan research group. (KHN is a editorially independent program of the foundation).

Paul Fronstin of the says that is the trend nationally.

“Deductibles have gone up. Co-pays have gone up. You see costing-sharing for out-of-network services have gone up,” Fronstin said. “It seems to have accelerated in the last few years. Health care is just continuing to take a bigger bite out of take-home pay.”

So even people with insurance are paying thousands of dollars out of pocket before their insurance kicks in. And even when it does, insurance picks up less then it used to — often a lot less.

More than 1 in 5 Americans had a problem getting insurance to pay for a hospital, doctor or other health care in the past year, according to a  by NPR, the Robert Wood Johnson Foundation and the Harvard School of Public Health.

Altman says this comes as many families are struggling to get by.

“This effects not only how people seek health care — they’re more reluctant to get it if they can put it off. But it also affects family budgets in a very real way, especially as we’re still coming out of recession and families are still crunched by a weak economy,” Altman said.

Cooper’s family has stopped taking trips, eating out, fixing up their house, or spending money on anything else they don’t have to. Their son gets by with hand-me-downs, she said.

“He’s five and growing out of everything. I haven’t been able to buy him any clothes and shoes. Those are things I haven’t been able to purchase because of the increase in the health care,” she said.

And Fronstin says the weak economy is driving more and more companies to cut back on coverage because of simple math — it’s the only way they can keep up with rising health care costs.

“Employers are trying to manage those costs. They’re trying to keep those cost increases as close to inflation as possible. And they’re doing everything they can to get their workers so that they think twice about the health care that they are using,” Fronstin said.

Cooper’s just grateful she’s getting her drugs every month. And she started those monthly blood tests again when her company changed insurance again this year. But it’s still not as good as it used to be. So she and her husband don’t go to the doctor when their get sick if they can avoid it. Same goes for their son.

“There were a couple of times where he got sick where I just tried to do the best I could with what I had whether it was children’s Ibuprofen or cooling him down with cool rags and that sort of thing,” she said.

And Cooper can’t help but worry about the next company meeting about her family’s health plan.

“It changes every year so I really have no clue what’s going to happen next year and with them making that change I really don’t know what to expect every year,” she said.

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‘s Shots blog.

Should women in their 40s routinely get mammograms to detect breast cancer?

Two studies released Monday aim to help resolve that question, which is one of the most intense debates in women’s health. °Õ³ó±ðÌý identify which women in their 40s are most likely to benefit from routine mammograms.

For years, the mantra was that regular mammograms save lives. So many people were stunned in 2009 when an influential panel of experts questioned that assumption.

°Õ³ó±ðÌý recommended against all women in their 40s getting a mammogram every year or two.

“The benefit of mammography in the 40s is not as large as it is later in life and is not as large as most people assume it to be. And there are some harms associated with mammography,” said  of the University of Missouri School of Medicine, a task force member.

Those harms include frightening women with false alarms, prompting them to come back for repeated exams and unnecessary biopsies. Mammograms may also cause women to undergo unneeded surgery, radiation, and chemotherapy.

“Mammography may pick up small tumors that never would have progressed to harm them in their lifetimes,” said , an oncologist at Georgetown University. “Yet they’ll undergo treatment for breast cancer when that disease if it had been never detected would have never bothered the woman.”

The task force did conclude that a mammogram every other year is warranted for for women in their 50s because their risk for breast cancer is higher.

So Mandelblatt and her colleagues decided to see if there were some 40-somethings who had about the same risk as women in their 50s. They analyzed data from millions of women, mammograms, and breast cancer cases from dozens of published studies and huge databases.

“The studies were designed to identify what was the risk level that would be the tipping point so that the benefits and harms would be the same as what’s currently recommended for starting at age 50?” Mandelblatt said.

In two papers published in the Annals of Internal Medicine, the researchers found that two types of women would benefit from regular mammograms in their 40s: those who have very dense breasts, and those who have a close relative — a mother, sister or daughter — who had breast cancer.

“They’re twice as likely to develop breast cancer as the average woman, and that higher risk of developing breast cancer tips the balance to having more benefit to the harms,” she said.

The studies will help guide women and their doctors, according to  of the University of California, San Francisco, who worked on the studies.

“If you’re a 40-year-old who’s at high risk of breast cancer then undergoing mammography every two years makes sense for that person. If you’re a 40-year-old person who’s at very low risk waiting til you’re 50 is reasonable,” she said.

But for a lot of women, the answer still remains far from clear, said  of the National Breast Cancer Coalition.

“There’s no absolute answer for women in their 40s or even in their 50s,” said Visco. It’s not as simple as “you fall into this category — you should be screened. That will save your life,” Visco said.

Others disagree with the papers, too.

“These papers are just several more in a series of papers that I think are misleading women and their physicians,” said , a radiologist at the Harvard Medical School. “And I think if women really appreciated what they’re being told they would be outraged.”

of the American College of Radiology worries the research could end up costing lives.

“This may discourage women who don’t have an identifiable risk factor from seeking screening, and therefore the potential lifesaving benefit of screening won’t be realized,” Lee said.

The American Cancer Society still recommends all women in their 40s get screened every year. And , the society’s chief medical officer, says he’s not ready to change that profile.

“I don’t think we’re ready to actually have as a widespread policy that we would use these profiles to determine who should get screened and who should not get screened,” said Brawley, who wrote an  published with the studies.

But, he says, the new studies are clearly a step in that direction.

“I could easily see in the next several years that we would be using these profiles,” Brawley said.

In the meantime, it’s up to doctors and their patients to weigh the pros and cons of mammograms for women in their 40s for themselves.

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A major medical group issued ethical guidelines on Monday that take the provocative position of urging doctors to consider cost-effectiveness when deciding how to treat their patients.

The American College of Physicians, the second-largest U.S. doctors’ group after the American Medical Association, included the recommendation in the, which provides guidance for some 132,000 internists nationwide.

“The cost of health care in the United States is twice that of any other industrialized countries and we are not providing care to as many people as they do in other places, and we don’t even have as good outcomes,” said, president of the group. “So given that, we really have to look at ways of doing things better.”

One way to do things better is for individual doctors to think harder about the tests and treatments they give their patients, she said. More is not always better; in fact, it can often do more harm than good, she said.

“Every time you prescribe something for a patient or subject them to some kind of investigation there’s a risk of harm,” she said in a telephone interview. “So the concept of doing less is actually a really good concept, not a negative concept.”

As a result, the sixth edition of the manual, which is being published in the current issue of the Annals of Internal Medicine, includes the following passage:

“In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.”

Now, Hood argues that considering cost-effectiveness would do far more than just help protect patients from costly and potentially dangerous tests and treatments they don’t really need:

“We also have to realize that if we don’t think about how resources are used in an overall sense then there won’t be enough health care dollars for our individual patients. So while concentrating on our individual patients and what they need we also to think on this bigger level both for their benefit and for the well-being of the community at large.”

Many health care policy experts say the guidelines are right on target. In an accompanying the new guidelines, bioethicist of the University of Pennsylvania calls the statement “truly remarkable” for taking on the sensitive issue so directly.

Emanuel has advised the Obama administration on health policy and has long advocated this way of thinking. It’s a position that provokes strong resistance from those worried about the federal government rationing health care.

And even those who support the concept in theory, are alarmed by some of the language used, especially this part:

“Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”

The word “parsimonious” strikes some as worrisome, almost Dickensian. “It’s going well beyond just giving advice to physicians about just being cognizant of the fact that we should use resources efficiently,” said of the American Enterprise Institute. “I think that that’s generally accepted in medical practice right now.”

For Gottlieb, a parsimonious approach to medicine “really implies that care should be withheld. There’s no definition of parsimonious that I know of that doesn’t imply some kind of negative connotation in terms of being stingy about how you allocate something.”

For her part, Hood defended the wording, arguing the college simply means that efficient health care is good health care — both economically and medically. “Parsimonious is a good word in the sense that it means that you use only what’s necessary,” she said. “I don’t see a particular problems with that. Maybe it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate. But I don’t think that is the real meaning of that word.”

Even those who think doctors have to find ways to be more efficient, think the college’s position could fuel the already polarized struggle over costs. And that’s a fight that’s only likely to intensify in the coming year as the debate over the federal health care overhaul continues and the government pours millions of dollars into research aimed at providing doctors with better information about which tests and treatments work best.

“If you say say certain things will not be cost-effective, they’re not worth the money, well that’s rationing, particularly if some patients might benefit or simply some might desire it whether they benefit or not, whether it benefits them or not. So that’s where this all becomes a real viper’s pit,” said of the Hastings Center, a bioethics think tank.

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