Season 3, Episode 7: Prevention as self-care: Shifting the paradigm
In this episode, we’re joined by Carrie Whitcher, chief quality officer and vice president of quality performance at UPMC Health Plan; Dr. Bob Edwards, chair of ob-gyn at the University of Pittsburgh, and the chief medical officer of UPMC’s Community and Ambulatory Services Division, to discuss preventive care for women.
Cancer screenings save lives.
The American Cancer Society offers guidelines for cancer screenings by age. For example, women starting at 25 should be screened for cervical cancer. Women who may be at a higher risk for colon cancer due to family history may have to be tested earlier than others who do not. Talk to your doctor about your family history, and get your screenings.
Screening exams, genetic testing, and risk reduction services are available at UPMC Hillman Cancer Center. Call 412-623-1266.
Women who are living below the poverty level can access some cancer screenings and other services through a new Pennsylvania Department of Health initiative. Learn more about the Pennsylvania Breast & Cervical Cancer Early Detection Program, or call 1-800-215-7494.
The African American Cancer Support Group through UPMC aims to address factors leading to a higher rate of deaths from cancer among Black women. For more information, call 412-623-1266.
Dr. Ellen Beckjord: In this episode, Carrie Whitcher, chief quality officer and vice president of quality performance at UPMC Health Plan, joins us to discuss preventive care for women. Welcome, Carrie.
Carrie Whitcher, MHA: Thank you, Ellen.
Dr. Ellen Beckjord: Also with us is Dr. Bob Edwards, chair of ob-gyn at the University of Pittsburgh, and the chief medical officer of UPMC’s Community and Ambulatory Services Division. Dr. Edwards will also weigh in on this important health improvement topic. Welcome, Dr. Edwards.
Dr. Bob Edwards: Thank you, Ellen.
Dr. Ellen Beckjord: Really appreciate you both being here. So, I’d like to start by talking about some data revealing a concerning trend, showing that women routinely don’t keep preventive care appointments.That can mean a lot of different things when we talk about preventive care appointments. But, Carrie, if I could start with you. Can you give some examples of preventive care and talk about why it’s so important to women’s health?
Carrie Whitcher, MHA: Absolutely. Preventive care is a form of self-care and overall wellness. It’s how we can proactively prevent illness and engage in healthy behaviors to optimize our health for the long term. Women, in particular, may put off their own care because they are caregivers for others and tend to put the needs of others ahead of their own. I know I’m guilty of this, as a busy working mom; however, I think we all know the importance of taking the time to care for ourselves first so that we can best care for others.
Dr. Ellen Beckjord: And do you think that the time requirements and the logistics of scheduling preventive care appointments and attending them, are there ways that that has gotten easier in recent years for women and for everyone who’s engaging in preventive care?
Carrie Whitcher, MHA: Absolutely. We have worked diligently to assure that women have access to preventive screening, and we’ve done this through a variety of new convenient approaches, such as appointment scheduling, online scheduling in particular, for breast cancer screening.
We offer Health Care Concierges who can support our members in getting appointments scheduled, and we’ve also enhanced a variety of community-focused programs to meet our members where they are in the community. And one recent example of this, if I might, is a collaboration with UPMC Magee-Womens Hospital to hold Mamm-o-Glam events at faith-based organizations as part of our Medicare Faith and Wellness Program. And at these events, we’re providing free transportation to the imaging location. We’re offering hand and chair massages and mini manicures, and free blood pressure checks as well. So, those are just a few examples of how we’re looking to really make a difference, to assure women get the care that they so need and deserve.
Dr. Ellen Beckjord: Sticking with the topic of routine preventive screening, Carrie, could I ask you to comment on what we know about any continued or lingering effects of the COVID-19 pandemic on women staying up-to-date in recommended preventive screening?
Carrie Whitcher, MHA: Yes, we have absolutely seen lingering negative effect of the pandemic on preventive screening, and it’s through many of those approaches that I just described that has afforded us an opportunity to really mitigate that and to assure that we’re playing catch-up and getting our members, and certainly our women, the care that they need to assure that they’re getting the right preventive care.
Dr. Ellen Beckjord: It was so interesting, you know, one of many, of course, observations about the pandemic, but the real shift in thinking through the public health lens about infectious disease, when it feels like we’ve been so focused on noncommunicable and more chronic diseases that are a function of many things like weight and lifestyle impact. So, what a shift and can appreciate that, that lingering negative effect to just stay engaged in preventive screening for noncommunicable diseases. So important. So, it sounds like we’re still working to get back to our prepandemic baseline and that we always want to be trying to optimize participation in preventive care.
Well, Dr. Edwards, I’d like to turn to you. So you’re an oncologist focused on cancers that affect women primarily. Can you share some examples of preventive screening that help detect cancer when it may be easier to treat? And can you also talk about some types of cancer, where we really don’t have good secondary prevention options?
Dr. Bob Edwards: Yes. So to be clear, we’re really going to be talking about three types of cancer in women: Breast cancer, which of course has the highest profile both nationally and in terms of prevention strategies; cervix cancer, which is a cancer that afflicts many, many women in the United States, but in international situations is the second most common cause of cancer death in women, so, less of a problem in this country because of our advanced screening programs; and the third cancer, which we don’t currently have good screening for, is ovarian cancer. And that’s largely because this cancer comes on very slowly, around the time of menopause in women who can have many other symptoms that are associated with aging that could be confused with the cancer, and it makes it very hard to diagnose this cancer in any sort of screening modality as we can with breast and with cervix cancer.
What we’re referencing here for screening for breast cancer, we’re primarily talking about screening mammography. Now, there are different types of mammography, but screen mammography is a very specific screening test that’s performed across most health systems and supported and covered by most insurance plans nationally. And screening mammography involves a radiologic or X-ray test on the breast. The technology around this screening has gotten much, much better and much more sensitive over the years. But the principle of how screening mammography is done is really pretty similar. And it is the primary screening test for breast cancer.
For cervix cancer, cervix cancer really requires a pelvic exam and a visit to a provider. And that provider can then access the female pelvic organs, place a speculum and collect a specimen from the upper genital tract.
More recently, we have begun to do research on women’s self-testing themselves with Pap smears they collect at home. But that’s not ready. And, so, unfortunately, we’re still going to ask women to continue to see their providers for their testing. What has changed is we are reducing the number of tests most women have to undergo. And we’re starting testing a little bit later because we found when we started testing too soon, women were getting many, many unnecessary tests. So, now the normal recommendation is after age 21, or two to three years after beginning to be sexually active. And that’s the current recommendation for Pap smear testing.
For ovarian cancer, we really don’t have a good screening test, but family history can allow us to do genetics screening in certain populations that have family members with either breast or ovarian or even some other cancers in the family, like thyroid or pancreas. They may be at risk, but that requires patients being in tune to their own family history backgrounds.
But probably more important from a public health perspective is really human papillomavirus. Vaccine prophylaxis is in the process of revolutionizing cancer prevention, where screening tests have to be done repetitively. The human papillomavirus vaccination appears to be a single initiative event, and if it’s performed before a woman becomes sexually active, she appears to have a lifetime preventive risk of cervical cancer approaching zero. So it’s really transformative.
Other examples that probably are not quite as effective as those two that I mentioned, of course, are mammography, which is important to do, but has pros and cons with it, particularly around the radiation exposure. But we, as you are aware, just recently as a medical society, moved back the screening again to age 40. And that’s because the risk-benefit analysis began to show that for many women, initiating screening earlier actually does lead to more prevention of disease when it can still be treated and cured, basically.
Dr. Ellen Beckjord: I’d like to ask you also a little bit about genetic testing, but before I do, your comment about the recommended age for initiating mammography moving back to 40. So, I remember when it was moved to 50 and boy, was that a communication challenge for the medical community. And, you know, I think that I’d love to hear your comments on how we’re doing from a public health communication or a sort of health communication, health education perspective. Because the fact is, these guidelines do change and they change as a result of good research and science that’s being conducted, that sometimes puts out a different answer than the best one we had previously. And that sometimes, it seems like, unfortunately negatively affects the public’s trust in research or medicine. What are the consequences of that, do you think?
Dr. Bob Edwards: Those are really great points. I think change produces confusion, particularly in population-based initiatives, and that confusion leads to lack of compliance because patients and, frankly, some physicians get fatigued by having to deal with what the latest recommendations are. I think as someone that has worked in some of these screening guidelines nationally, the folks that are sitting around the table discussing this are just looking at the data, as you said, they may not be considering what the impact is on public health. I think change has [a] cost. And that cost can mean, as you pointed out, Ellen, a lack of trust. It can also mean that the change is hard to disseminate. And particularly for most cancers, it’s the patients with the highest disparities that are the least able to access those initiatives. And when you’re giving mixed messages, together with the financial and logistics struggles that many of our patients that have higher cancer rates syndrome population, we already have a trust issue. And when we begin to change things, it has a big impact on population health that I think needs to be part of the calculus.
Dr. Ellen Beckjord: Yeah, preventive care, sort of, on its surface seems like such a slam dunk and relatively simple. But, I think, whether we look at it through the perspective of just the effort that it takes to access and receive preventive care or how the messaging around it can be confusing and sometimes feel conflicting to the public. It’s more complicated than it first seems.
I’d love to hear you talk, Dr. Edwards, about a couple of, I guess, primary prevention plays. It may not be fair, I’m thinking about what you said regarding vaccines. And, if there are, if you care to comment, if you would like to on the HPV vaccine, as you said, like really, really revolutionary. Are there other vaccines like that in the pipeline related to cancer that you think may come to fruition and be available to the public, say, in the next decade? But I also would love to hear your thoughts on the current state of genetic testing, which again, is not really necessarily a primary prevention play, though for women who know, for example, that they carry certain genes that significantly elevate their risk of breast or ovarian cancer, they can sometimes have surgical intervention that really does prevent the opportunity for those cancers to occur. But where are we with respect to genetic testing? Is that a rapidly evolving field? And is it a place where we really do need to continue to try to educate the public on what types of genetic testing might be relevant for whom and how to access it?
Dr. Bob Edwards: Thank you for both those questions. First, back to the vaccination issue. If you look at the number of solid tumors internationally, virus-associated cancers are probably 40 percent of the total population. So, in that list would include human papillomavirus, not just for cervical cancer, but also for other genital tract diseases in both men and women. And more recently, the preventive aspects of HPV vaccination on head and neck cancers is also coming into light as a very important component of cancer prevention strategies.
There are other pathogens that have now been identified associated with ulcers and stomach cancers and perhaps the Epstein-Barr virus with Hodgkin’s lymphoma and nasopharyngeal cancer. So, I think this trend of vaccination for viral diseases that can lead to cancer and the important part is there’s a large period of time between when the virus is contracted and when you get the cancer. So, the vaccinations tend to have to happen early in an individual’s lifespan to be effective because many of us are colonized with these viruses in our teens and 20s for a variety of reasons. And, so, if we don’t have the correct preventive strategy for the populations which differ around the world, they are going to be less effective.
Now, getting to genetics testing, I think this is a rapidly moving field. But what is becoming very clear is that as genetic testing costs are going down, the adoption of genetic testing is increasing rapidly. Unfortunately, I just operated on a patient four weeks ago who had a family history of mother dying of ovarian cancer, mother’s sister died of breast cancer.
And, in fact, she had a BRCA mutation and unfortunately had advanced ovarian cancer. And if that family had been tested, up to three different cancers might have been prevented.
And the prevention strategies I will freely admit are not subtle treatments. They are removing the ovaries and removing the tubes — and in some instances where there’s very clear, high risk, actually removing the breast. So, I don’t want to make light of what the implications are for positive testing. But folks — like when Angelina Jolie came out — it really raised awareness. But unfortunately, as you get out into more rural areas, the awareness from both the providers and the patients is just not there. And unfortunately, it continues to be an issue. I think public awareness with genetics testing for cancer predisposition is probably the next major tranche of preventive strategies working with our Health Plan associates and with the U.S. government. That will be the next push, in my opinion, after the vaccination strategies.
Dr. Ellen Beckjord: Diagnostic tools and routine visits with health care providers are really key aspects of preventive care. But are there other preventive measures that either of you would like to talk about that women can embrace to help detect health issues early, like educating ourselves on common symptoms that can indicate a more serious condition? Carrie, I’d start with you.
Do you have any ideas that you’d like to share around just kind of a more holistic approach to what preventive health can look like and things that maybe women can or ought to think about initiating on their own?
Carrie Whitcher, MHA: Thanks, Ellen. I’ll just play off of Dr. Edwards’ expertise and the importance of being aware of your family history and doing your homework to know what common symptoms are that you need to look for, as well as thinking about what else you could be doing to learn more. So I’m just a big advocate of knowledge is power.
And, so, I think it’s really important to keep empowering women to ask — ask the questions. Educate yourself on risk factors. Know what you can be proactively doing from a healthy activity perspective to truly prevent illness in the future.
Dr. Ellen Beckjord: So, let’s talk a little bit more about some of those, I guess, more foundational lifestyle behaviors, because while a lot of preventive care is delivered in the context of health care and we think about other things that women, or anyone, can do to really prevent different kinds of chronic conditions, it does relate to these foundational behaviors of how we move, what we eat. So, Dr. Edwards, what are your thoughts on just the role of these lifestyle behaviors as part of a holistic view of preventive care?
Dr. Bob Edwards: I think the use of lifestyle behavior, preventive strategies, has many benefits to the individual woman.
First of all, many women will seek out buddies or partners to exercise with, probably more so than men do. And that might include a pet or it might be neighbors down the street or a small group that either runs or walks together. The idea that exercise has to be formalized and regimented is probably hurting some of the benefits women get from — or anybody gets from — just walking every day.
And the more you walk and the better you eat and you begin to see maybe some of the pounds come off and maybe some of the things that you didn’t recognize about yourself get better. Then you start to feel better about yourself. And it can be a very self-fulfilling cycle. Kind of the opposite of what tends to happen when we’re sedentary. So, I think the mindset of exercise, the mindset of healthy choices in eating is infectious and we need to be promoting it. It doesn’t really cost anything except for fresh fruits and vegetables that cost a little more. But most of this is actually free or can be had at a very low cost.
Dr. Ellen Beckjord: Yeah, that’s a great point. And much like the logistics around receiving preventive care that can only be accessed through testing and procedures done in a health care provider office, these lifestyle behaviors are, in some ways, more accessible in that, as you said, they’re kind of available to most of us almost all of the time. But it is just that time factor.
I often find it important to point out that health is one of the things that still takes time. You know, we live in a sort of modern American culture that really seeks to engineer time out of every equation. But some things still take time. Good relationships take time. I think health is one of those things that still takes time. And making that time and having the privilege to take that time are both really important factors. I think often as time is one of our most important determinants of health in a place where a lot of inequity lives. But folks thinking about just acknowledging that health takes time and then figuring out how to make sure that people have equitable access to take time to care for themselves is really important.
Dr. Bob Edwards: Can I just add one more thing about that? When you’re taking care of yourself, when you’re out walking or you’re taking time for yourself, talk to somebody, put down your phone. I see everyone now when they’re walking, they’re looking at their screen, you know. I think we’re losing an opportunity, by being efficient, to not build relationships. And I do this with my kids, particularly my girls all the time, is put the phone down and talk to each other while you’re doing some group activity or while you’re exercising.
Dr. Ellen Beckjord: Yeah. What a great, what a great idea. And it really does then double duty for both your physical health and sort of your mental health and your social health. And it’s important for us to remember how to connect with one another in real time and not always through technology.
Carrie Whitcher, MHA: One final comment I’ll add on that is, is role-modeling and the influence that we have as women to interject that way of living to our children, to our grandchildren, to our nieces and nephews, et cetera. So, again, just another way in which we as women, as caretakers, can serve as a role model and continue to support overall health, not just for us, but the families that we serve every day.
Dr. Ellen Beckjord: And, so, Carrie, as you had said, knowledge is power. We look back and it really hasn’t been over that long of a time horizon. And even when I was doing research at the National Cancer Institute, a lot of what I was studying, and it was in 2005, which really isn’t, it’s almost 20 years ago, but that’s not really that long.
You know, what had happened is that there had been this sort of democratization of information because of the internet, and that really changed the information environment. And it compelled organizations like the National Cancer Institute or the American Cancer Society or the CDC to begin to be really thoughtful about how their information environments represented on the internet could be best designed for consumer use. I think what happened next is that the online information environment became significantly more accessible through the use of smartphones. So, now you didn’t have to be at a computer or on a web browser to get to the internet. Now, the internet was in your pocket constantly. And then, of course, not long after that was the emergence of social media, which just exponentially, I think, complicated the information environment.
But it’s very true that the information environment is a pretty diverse and kind of wild and wooly place, and people can and should seek assistance from trusted sources, like their health care providers or people in their life who they trust with decisions that they might make to understand where and from whom the best information is available, because all of it is available now.
Carrie, if I could ask you, from a health insurer perspective, what tools does UPMC Health Plan provide to help its female members prioritize preventive health care?
Carrie Whitcher, MHA: First and foremost, UPMC Health Plan has a strong commitment to the health and well-being of our members. We are your partner in care far before a health care event occurs and are here to support all of your preventive health care needs. UPMC Health Plan covers screenings at 100 percent and as a Health Plan member, completing these preventive screenings can provide additional benefits such as reducing your health care deductible and earn incentives.
Prescription for Wellness is another amazing tool where we offer health coaching and care managers to help prioritize self-care. This can provide that necessary encouragement and motivation to continue to eat healthy and make those healthy lifestyle choices. I think it’s so important that women intentionally prioritize their own health journey, and this can really start with some very simple steps, such as taking time to move your body in whatever capacity you can, even doing one thing that you love every day that will contribute to your mental well-being. Something is just always better than nothing at all.
And I often remind myself of a quote that I’ve read that states, “If you don’t make time for your wellness now, you will be forced to make time for your illness later.” So, if you don’t make time for your wellness now, you will be forced to make time for your illness later. And I really hope this is as inspiring to our listeners as it has been to me through the years. And, certainly, it’s never too late to get on the path to take care of you, because you matter.
Dr. Ellen Beckjord: Oh, that’s so well said. I love that. Thanks so much for sharing that quote, Carrie, Dr. Edwards, I want to thank you so much for being guests on this episode of Good Health, Better World, and taking the time to talk with us about the importance of preventive care. Carrie, thank you so much.
Carrie Whitcher, MHA: Thank you, Ellen. It was a pleasure.
Dr. Ellen Beckjord: Dr. Edwards, thanks for being here.
Dr. Bob Edwards: Thank you, Ellen. It’s been my pleasure.
Dr. Ellen Beckjord: Women are more likely to go without the health care they need, which can cause significant harm to their health. You can learn more about resources UPMC Health Plan offers to help women live their healthiest life at postindustrial.com/goodhealth.
In accordance with the Patient Protection and Affordable Care Act of 2010 (PPACA), many preventive services, including screening tests and immunizations, are covered by UPMC Health Plan at no cost to members. Preventive care will be covered at 100 percent only when it is received from a participating provider and it is billed as preventive. A separate cost may apply if additional medical services are received during the same visit or if your preventive care appointment becomes diagnostic in nature. Please call Member Services at the number on your member ID card should you have questions about preventive services covered under your plan.
Dr. Ellen Beckjord, MPH, is host of the Good Health, Better World podcast.
Ellen is a behavioral scientist, epidemiologist, and licensed clinical psychologist working at the intersection of population and digital health. A long-time member of the Society of Behavioral Medicine, Ellen currently serves on the board of directors as president-elect.
Her work focuses on promoting health, wellness, and health behavior change. She is vice president of population health and clinical optimization for UPMC Health Plan based in Pittsburgh.
Ellen trained at the University of Vermont, where she worked with cancer survivors and their families, at Vanderbilt University, and at the Johns Hopkins Bloomberg School of Public Health.
She completed post-doctoral research at the National Cancer Institute in the Health Communication and Informatics Research Branch within the Division of Cancer Control and Population Sciences. She spent nearly five years in academic medicine at the University of Pittsburgh and Hillman Cancer Center.
Ellen also is the co-author of “Porchtraits” in which she interviewed people in Pittsburgh during the early months of the COVID-19 pandemic about what they were learning, missing, enjoying, what surprised them, and what they felt hopeful about.
Ellen’s guiding principle: “Lead with love.”
This podcast is proudly presented by