Prophylactic tamoxifen
1
168 Profits, pay, and perks Health care in the US has become dominated by businessmen who are often more concerned about pay- cheques, profits, and "perks" than patient care, said witnesses at a Con- gressional hearing on the financial practices of the US health-care indus- try held by the Subcommittee on Oversight and Investigations of the Committee on Energy and Commerce. One witness, Graef S Crystal, an expert on executive compensation, re- ported on the earnings of the chief executive officers (CEOs) of 26 major US health-care companies. The lowest paid CEO in the group earned $700 000 in 1992, Crystal said, while one executive, profiting from stock options, earned more than$127 mil- lion. Crystal found that the median CEO in his sample earned between $2.5 million and$2.9 million in 1992, depending on whether statistical out- liers were excluded, and that pay of executives was rising far faster than that of other health-care workers. In : 1985, for example, the median CEO pay was 54 times that of a staff nurse- by 1992 it was 85 times. : Auditors from the US General Accounting Office (GAO) told the committee that the cost of care now includes some questionable expenses. At the committee’s request, the GAO investigators examined the$2.1 mil- lion administrative and office ex- penses filed by the Hospital Corpor- ation of America (HCA) in its Medicare costs report and found that $1.1 million were either "unallowable, questionable, or unsupported". Among the costs that GAO judged to be unallowable were$17 755 for alco- holic beverages served at employee functions and$51013 for enter- tainment, including$14 225 for a "theme party",$3500 for a singing group, and$1710 for a sailing regatta. "While Medicare costs principles do not specifically discuss these type of entertainment costs", the GAO said, "such costs, in our opinion, are not related to patient care". HCA officials disputed the GAO’s conclusions, pointing out the Medi- care reporting rules were vague and did not expressly forbid these types of expenditure. HCA officials added that employee meetings where such enter- tainment costs are incurred boost company morale and increase staff effectiveness. It would be better, said Mr Jack Bovender, HCA executive vice- president and chief operating officer, if Congress spent its time trying to reduce unnecessary paperwork, citing a recent study that estimated that the administrative costs of health care in 1991 cost$125.6 billion-17% of the nation’s total health-care expendi- tures. Commenting on his committee’s investigations, chairman John D Dingell, a Michigan Democrat, con- cluded, "Too many in the medical marketplace have been only too willing to take financial advantage of the absence of a comprehensive national health policy". Michael McCarthy Prophylactic tamoxifen The Department of Health has approved the tamoxifen trial in healthy women at high risk of breast cancer. 15 000 women with a 1 in 6 lifetime risk of breast cancer will be recruited from the autumn. Women have to meet one of the entry criteria. For those aged 45-65 these criteria are: a first- degree relative aged under 50 with breast cancer; a first-degree relative with bilateral disease; two affected first or second degree relatives; nulliparity and an affected first- degree relative of any age; biopsy- confirmed lobular carcinoma in situ (LCIS) or atypical aplasia; or biopsy findings of proliferative disease and breast cancer in a first-degree relative of any age. In women aged 35-44 the criteria are: a first-degree relative with bilateral disease diagnosed at less than age 40; two first- degree relatives diagnosed at less than age 50; or biopsy-proven LCIS. No teratoge- nicity studies have been done for tamox- ifen, so women pregnant or at risk of pregnancy will not be recruited. : At a press conference on July 9, the main trialists (Prof M Baum, Dr T Powles, Dr J Cusick) said that for the 85 women who have become pregnant while on tamoxifen no fetal abnormalities have been reported. The trialists believe that the risk of liver tumours (see Lancet April 24, p 1086) is . unlikely to be significant in man. Powles said that although 2 cases have been re- ported, the women were on twice the dose (40 mg daily) to be used in the UK trial. About 6 million women worldwide have received tamoxifen, and he felt that the lack of reports of liver carcinoma was reassur- ing. The trialists admitted that there is probably a small undefined risk of endome- trial cancer, but pointed out that this disease is treatable and preventable. Furthermore, tamoxifen reduces mortality (see Lancet 1992; 339: 1-15 and 71-85) and has protective effects of the drug in heart disease and osteoporosis. : Approval for the trial has not been without controversy. The Medical Research Council withdrew its support on the grounds of liver toxicity in rats and the ethical issue of giving an anticancer drug to healthy women (see Lancet 1992; 339: 735). The trial has, however, been approved by the Committee on Safety of Medicines and by a large ad-hoc national ethics com- mittee. Local ethics committee approval will be sought by the individual recruit- ment centres. The trial is double-blind, placebo-controlled, and randomised and similar trials are underway in Australia and the USA. Switzerland, France, Nether- lands, Austria, Spain, Germany, Finland, and Denmark may participate, and the . trialists hope that about 50 000 women will v eventually be recruited world wide. Stephanie Clark Crisis cards The House of Commons Select Committee on Health has rejected proposals by the Royal College of Psychiatrists for introduc- ing community supervision orders for mentally ill patients being treated out of hospital.l The committee has instead expressed interest in crisis cards, a form of advance directive or treatment contract which the patient makes when well. The committee believed that, as pro- posed by the college, the consent that would be obtained from the patient for a community supervision order would not be "real" and that the proposals focused too much on medication as treatment. The committee was also concerned about the extent to which a person’s freedom might be limited by the proposals and by insuffi- cient support from other groups for the college’s proposals. The committee does acknowledge, though, that there are many important legal and philosophical issues about advance directives that have to be addressed. Vivien Choo 1 House of Commons Health Committee. Community supervision orders. London: HM Stationery Office. 1993: Pp 36. £10. ISBN 0-10-021-243-3.
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Transcript of Prophylactic tamoxifen
168
Profits, pay, and perks
Health care in the US has becomedominated by businessmen who areoften more concerned about pay-
cheques, profits, and "perks" thanpatient care, said witnesses at a Con-gressional hearing on the financial
practices of the US health-care indus-try held by the Subcommittee on
Oversight and Investigations of theCommittee on Energy and Commerce.One witness, Graef S Crystal, an
expert on executive compensation, re-ported on the earnings of the chiefexecutive officers (CEOs) of 26 majorUS health-care companies. Thelowest paid CEO in the group earned$700 000 in 1992, Crystal said, whileone executive, profiting from stockoptions, earned more than$127 mil-lion. Crystal found that the medianCEO in his sample earned between$2.5 million and$2.9 million in 1992,depending on whether statistical out-liers were excluded, and that pay ofexecutives was rising far faster thanthat of other health-care workers. In :
1985, for example, the median CEOpay was 54 times that of a staff nurse-
by 1992 it was 85 times.: Auditors from the US General
Accounting Office (GAO) told the
committee that the cost of care nowincludes some questionable expenses.At the committee’s request, the GAO
investigators examined the$2.1 mil-lion administrative and office ex-
penses filed by the Hospital Corpor-ation of America (HCA) in itsMedicare costs report and found that
$1.1 million were either "unallowable,questionable, or unsupported".Among the costs that GAO judged tobe unallowable were$17 755 for alco-holic beverages served at employeefunctions and$51013 for enter-
tainment, including$14 225 for a
"theme party",$3500 for a singinggroup, and$1710 for a sailing regatta."While Medicare costs principles donot specifically discuss these type ofentertainment costs", the GAO said,"such costs, in our opinion, are not
related to patient care". HCA officials disputed the GAO’s
conclusions, pointing out the Medi-care reporting rules were vague anddid not expressly forbid these types ofexpenditure. HCA officials added thatemployee meetings where such enter-tainment costs are incurred boost
company morale and increase staffeffectiveness.
It would be better, said Mr JackBovender, HCA executive vice-
president and chief operating officer,if Congress spent its time trying toreduce unnecessary paperwork, citinga recent study that estimated that theadministrative costs of health care in1991 cost$125.6 billion-17% of thenation’s total health-care expendi-tures.
Commenting on his committee’s
investigations, chairman John DDingell, a Michigan Democrat, con-cluded, "Too many in the medicalmarketplace have been only too willingto take financial advantage of theabsence of a comprehensive nationalhealth policy".
Michael McCarthy
Prophylactic tamoxifen
The Department of Health has approvedthe tamoxifen trial in healthy women athigh risk of breast cancer. 15 000 womenwith a 1 in 6 lifetime risk of breast cancerwill be recruited from the autumn. Womenhave to meet one of the entry criteria. Forthose aged 45-65 these criteria are: a first-degree relative aged under 50 with breastcancer; a first-degree relative with bilateraldisease; two affected first or second degreerelatives; nulliparity and an affected first-degree relative of any age; biopsy-confirmed lobular carcinoma in situ
(LCIS) or atypical aplasia; or biopsyfindings of proliferative disease and breastcancer in a first-degree relative of any age.In women aged 35-44 the criteria are: afirst-degree relative with bilateral diseasediagnosed at less than age 40; two first-degree relatives diagnosed at less than age50; or biopsy-proven LCIS. No teratoge-nicity studies have been done for tamox-ifen, so women pregnant or at risk of
pregnancy will not be recruited. :At a press conference on July 9, the main
trialists (Prof M Baum, Dr T Powles, Dr JCusick) said that for the 85 women whohave become pregnant while on tamoxifenno fetal abnormalities have been reported.The trialists believe that the risk of livertumours (see Lancet April 24, p 1086) is .
unlikely to be significant in man. Powlessaid that although 2 cases have been re-ported, the women were on twice the dose(40 mg daily) to be used in the UK trial.About 6 million women worldwide havereceived tamoxifen, and he felt that the lackof reports of liver carcinoma was reassur-
ing. The trialists admitted that there is
probably a small undefined risk of endome-trial cancer, but pointed out that thisdisease is treatable and preventable.Furthermore, tamoxifen reduces mortality(see Lancet 1992; 339: 1-15 and 71-85) andhas protective effects of the drug in heartdisease and osteoporosis.
: Approval for the trial has not beenwithout controversy. The MedicalResearch Council withdrew its support onthe grounds of liver toxicity in rats and theethical issue of giving an anticancer drug tohealthy women (see Lancet 1992; 339: 735).The trial has, however, been approved bythe Committee on Safety of Medicines andby a large ad-hoc national ethics com-mittee. Local ethics committee approvalwill be sought by the individual recruit-ment centres. The trial is double-blind,placebo-controlled, and randomised andsimilar trials are underway in Australia andthe USA. Switzerland, France, Nether-lands, Austria, Spain, Germany, Finland,and Denmark may participate, and the .
trialists hope that about 50 000 women will veventually be recruited world wide.
Stephanie Clark
Crisis cards
The House of Commons Select Committeeon Health has rejected proposals by theRoyal College of Psychiatrists for introduc-ing community supervision orders for
mentally ill patients being treated out ofhospital.l The committee has instead
expressed interest in crisis cards, a form ofadvance directive or treatment contract
which the patient makes when well.The committee believed that, as pro-
posed by the college, the consent thatwould be obtained from the patient for acommunity supervision order would not be"real" and that the proposals focused toomuch on medication as treatment. Thecommittee was also concerned about theextent to which a person’s freedom mightbe limited by the proposals and by insuffi-cient support from other groups for the
college’s proposals. The committee doesacknowledge, though, that there are manyimportant legal and philosophical issuesabout advance directives that have to beaddressed.
Vivien Choo
1 House of Commons Health Committee.
Community supervision orders. London:HM Stationery Office. 1993: Pp 36. £10.ISBN 0-10-021-243-3.
