The more health-related social needs factors a woman has, the less likely she is to get a mammogram; that matters in Kentucky

Centers for Disease Control and Prevention graphic

By Melissa Patrick
Kentucky Health News

A Centers for Disease Control and Prevention study says the more health-related social needs a woman has, the less likely she is to get a mammogram. 

The study defines health-related social needs, or HRSNs, as social conditions that adversely affect a person's health. Examples include feeling socially isolated, loss of work or reduced hours, dissatisfaction with life, the cost to access health care, a lack of transportation, and receiving food stamps. HRSNs are some of the social determinants of health. 

Using data from the CDC's 2022 Behavioral Risk Factor Surveillance System, a continuing national survey, the researchers found that mammogram use was almost 20% lower among women between the ages of 50 and 74 who had three or more HRSNs, compared to women who had no such needs.

The report did not provide state-level data, but health-related social needs are more prevalent in Kentucky than in most states.

In Kentucky, 59% of women aged 40-49 and and 72% of women aged 50-74 reported having had a mammogram within the previous two years, according to the 2022 BRFSS data. The rate for younger women 40-49 was the same as the national average, but the rate for those 50-74 was 4.6 percentage points less.

Among U.S. women aged 50 to 74 with no adverse HRSNs, 83 percent had a mammogram in the last two years, while that was true for only 66 percent of those with three or more adverse HRSNs.

“We have to address these health-related social needs to help women get the mammograms they need,” Dr. Debra Houry, chief medical officer at the CDC, said in a news release. “Identifying these challenges and coordinating efforts between health care, social services, community organizations, and public health to help address these needs could improve efforts to increase breast cancer screening and ultimately save these tragic losses to families.”

Breast cancer causes more than 40,000 deaths in U.S. women each year, according to the news release. 

Between 2016 and 2020, Kentucky's breast-cancer rate was 126.7 per 100,000 people and its breast cancer death rate was 21.6 per 100,000, according to the National Cancer Institute State Cancer Profiles. The national rate was 19.6.

The report adds that Black women and women of lower socioeconomic status are more likely to die from breast cancer. 

The U.S. Preventive Services Task Force currently recommends that women aged 50 to 74 get a screening mammogram every two years and that women ages 40 to 49 talk to their health-care providers about when to start and how often to get a mammogram.

Most health-insurance plans cover the full cost of screening mammograms, but follow-up diagnostic imaging is not always covered.

To address this, Kentucky lawmakers recently passed House Bill 115, which eliminates co-payments and cost-sharing requirements for high-risk individuals who need follow-up diagnostic imaging to rule out breast cancer. Gov. Andy Beshear signed HB 115 into law on April 5. It takes effect Jan. 1, 2025. 

“Thousands of Kentuckians require diagnostic and supplemental breast imaging every year, yet many forgo them due to out-of-pocket costs. Not anymore," Molly Guthrie, vice president of policy and advocacy at the breast-cancer foundation Susan G. Komen, said in a news release. "This life-saving legislation means they will now receive the breast imaging they require, leading to an earlier breast cancer diagnosis and often better health outcomes."

Lt. Gov. Coleman reflects on her preventive double mastectomy

Lt.Gov. Jacqueline Coleman (KL photo by Sarah Ladd)

By Sarah Ladd
Kentucky Lantern

Kentucky Lt. Gov. Jacqueline Coleman knew for a long time that one day she might learn cancer was at her door.

Her family history put her on heightened alert; her mother, aunt and cousin all had breast cancer. So she “wasn’t shocked” when, in September, a routine mammogram — her first — concerned her health-care provider.

She went for more tests, including magnetic resonance imaging and biopsy. After the biopsy she learned she needed surgery, either way. Her doctors were concerned about several areas in her breasts, and she was facing “biopsy and remove, biopsy and remove, times four.”

She knew immediately: “I don’t want to live like that.” Without the mastectomy, she faced “scans and screens and biopsies every six months for the rest of my life.”

“In a way, it was almost like I was waiting for this news,” she told the Kentucky Lantern during a sit-down interview in her Capitol office on Jan. 23. She would eventually undergo a double mastectomy on Dec. 18.

But as she wrapped up the last leg of a statewide re-election campaign with Gov. Andy Beshear, Coleman found herself in medical limbo. Screenings and tests defined her personal October and November, even as she debated her opponent on KET, traveled the state meeting voters and celebrating on election night.

“I’m going through the end of a campaign, which is … the most intense time, and I have all these questions,” she said. “And it was really hard to not know what was going to happen.”

The tests “just kind of get a little bit more invasive each time,” said Coleman, 41. “And of course, it takes time to … do the test, to have them read, to schedule the next one. It’s a frustrating process because you have more questions than answers, it seems, the entire time. But you’re also grateful that your doctors are being so thorough, and making sure to cover all the bases.”

In early December, Coleman was “relieved” to learn she could get a double mastectomy at Baptist Health in Lexington.

“I felt it would be irresponsible to have a three-year-old, and to not be as aggressive as I could be,” she said.

Coleman did not have cancer, but she didn’t know that until after her surgery, when her pathology results came back clean. “The one place that was a great concern came back benign, but had malignant potential,” she said. “And so I felt like I got ahead of it. And I feel like I made the right decision.”

At the mercy of disease

Coleman says she's “not the best person about going to the doctor,” but “I also know that being preventative gives you a chance.”

“When you’re reactive, you’re at the mercy of … It could be a disease,” she said.

Still, medical issues wait for no one.

“You’re fighting for your life, and you still have to pick the kids up, and you still have to go to the grocery, and you still have to go to work,” Coleman said. “The world doesn’t stop.”

If anything, she said, the whole experience left her with less patience for what she called “petty politics.”

“There are real problems in the world,” she said. “I think about the importance of women being empowered to protect their own health, to be trusted.”

 
Not alone 

After her surgery, Coleman got cards and letters from people all over the state telling her their stories about going through similar health challenges.

“It was a message of: ‘You’re not alone’,” she said. “But it was also a message of reassurance. And it was remarkable.”

Coleman said she finally feels like herself again, and is looking forward to getting back out in communities across Kentucky. And she plans to keep using her story to encourage others to seek preventive care — and to know there is a community of Kentuckians who relate to their journeys.

“I know how alone I felt when I got the news and when I tried to find my way and what was the right path for me,” she said. “And I don’t want other women to feel that way.”

Women from 40 to 49 should get mammograms every two years, and from 50 to 74, they should get the exam every year, according to the state Department for Public Health. To find out how to get a free or low-cost mammogram or cervical cancer screening, call 844-249-0708. Click here for more information.

Cancer is a leading cause of death in Kentucky, which has high rates of breast cancer. In 2021, Kentucky lost more than 10,000 people to cancer, according to the Centers for Disease Control and Prevention. Breast cancer is second only to lung cancer in its mortality nationwide, according to the American Cancer Society.

In a state thick with cancer, leaders of screening and research organizations targeted for cuts make cases for state money

Mammograms are a screening for breast cancer. (WTVQ image)

By Melissa Patrick
Kentucky Health News

Gov. Matt Bevin's proposed budget for the next two fiscal years calls for cuts to five cancer research and prevention programs, including screenings for breast, colon, cervical, lung and ovarian cancer, and for research on lung cancer, all of which plague the state.

The programs are included in a list of 70 that Bevin proposed to eliminate to save the state $85 million, or less than 1 percent of the overall budget. He has said these cuts are necessary to help fund the state's ailing pension system.

Dr. Whitney Jones, a Louisville gastroenterologist and founder of the Kentucky Cancer Foundation, which provides funds for colon-cancer screening, said he recognizes the challenges of balancing a state budget, but hopes the state will reconsider eliminating the colon cancer screening and prevention program. He said of Bevin, "We hope this is just his first position."

Jones, who also founded the Colon Cancer Prevention Project in Louisville, called the state's improvement from 49th to 19th for colo-rectal screening in the past 15 years, "the best public health story" in Kentucky.

He added that this was only possible because the state offered screenings to uninsured and under-insured Kentuckians, expanded Medicaid to those who earn up to 138 percent of the federal poverty level, and has a unique, multi-partner screening program -- all of which he said makes Kentucky "the envy of most states in the nation."

But he also said there is still work to be done, because Kentucky still leads the nation in colon cancer and remains in the top 10 for colon-cancer deaths.

Doug Hogan, a spokesman for the state Cabinet for Health and Family Services, said the state's screening programs, including those for colon, breast and cervical cancer, are no longer needed because they are now covered by all insurance plans with no deductibles or co-payments.

Jones acknowledged that the program needs to be restructured because of the Medicaid expansion, but argues that it is still necessary for several reasons. He said Kentucky still has a large number of people without health insurance; the federal law that requires almost all Americans to have insurance or pay a tax penalty will be repealed at the end of the year; the coming work requirements and premiums in Medicaid will lead to some people going without coverage; and there will be a continuing need for education and outreach about cancer and screening.

"There has to be a better way to cut out the bad and support or maintain the good," Jones said. "And I would just suggest that the Kentucky Colon Cancer Screening Program is the baby, and not the bathwater."

Lung cancer research targeted in a state that has the most of it

Another program set to lose about $5 million is the Lung Cancer Research Grant Program, a collaboration between the University of Kentucky and University of Louisville that is funded by funds from states' 1998 settlement with cigarette manufacturers. UK's portion is $2.4 million, spokesman Jay Blanton said.

Dr. Mark Evers of UK's Markey Cancer Institute said this statewide initiative seeds a number of pilot projects and "spans the gamut" from new lung-cancer therapies and treatments to new clinical trials and prevention strategies, such as lung-cancer screening. He said such pilot programs are often used to help get larger grants from the National Institutes of Health and other sources.

Evers noted that the Kentucky Lung Cancer Education Awareness Detection Survivorship Collaborative (the Kentucky LEADS Collaborative for short), now funded by a $7 million Bristol-Myers Squibb Foundation grant, is a great example of how a pilot project from this research grant program was able to get a larger grant to further its work.

"It really is a valuable mechanism for us to provide pilot funding for investigators to get the initial data so that they can carry that forward in larger extramural grants," Evers said.

He also noted that the research grant program is responsible for the Kentucky Clinical Trials Network, which he described as another joint venture with U of L that "pushes out" clinical trials for lung cancer, which have been conducted in about 90 percent of Kentucky's counties.

Asked if the program could survive without the state funding, Blanton, who sat in on the telephone interview with Evers, said, "We're just trying to get our arms around the numbers right now."

Asked why the program is important, Evers pointed to the state's high smoking rate, second in the nation, and its No. 1 rank in number of lung-cancer cases. "We've got a terrible problem with this in the state," Evers said.

When Kentucky researchers made a pitch to the National Cancer Institute, Evers said, "The first words out of their mouth were, 'What are you guys doing about your smoking problem?' So, it's really incumbent upon us to be able to have the resources to attack this by screening, prevention and treatment."

While Kentucky LEADS is on Bevin's list of programs that would get no state funding in the next two fiscal years, it has never received any, said Jamie Studts, a UK professor of behavioral science and the lead investigator for the collaborative. He said it had been slated to get $10,000 in each year of the current budget, but that Bevin had "red-lined" the allocation.

Studts said that the cut "doesn't directly affect us in terms of dollars, but indirectly it does send a message that the governor and this administration is not interested in making those kinds of efforts to address Kentucky's burden of lung cancer."

Breast and cervical cancer: state squeezes local health departments

As for the screening programs for breast and cervical cancer, Hogan said that in addition to these screenings now being covered by insurance, they are also operated by federal funds, so elimination of any state funds would not impact them.

Allison Adams, president of the Kentucky Health Department Association, said that while it's true that the breast and cervical screening programs have not received any state dollars for several years and get some federal funds, most of their funding for these programs come from local tax dollars.

For example, she said that in the fiscal year that ended in June 2017, local health departments received about $607,000 in federal funding for breast and cervical cancer screening, and the rest came from $2.3 million in local dollars. The programs serve about 20,000 patients a year.

Adams said the real challenge for health departments to continue such programs, or any of the other initiatives that involves direct patient care, is that Bevin's budget has added $38.5 million to their annual pension liability. She said that will force the departments to provide programs that focus on overall health, safety and prevention and look for ways to spend $1 to affect 10 people, instead of $10 to affect one.

"Local health departments need to be working on the prevention piece, and less on the treatment and intervention," Adams said, but they "will have to do their own prioritization and determine which programs have the absolute most health benefit for all of Kentuckians. We really have to make some tough decisions of where we are going to spend our money that's going to have the greater impact over the health of Kentucky."

The Ovarian Cancer Screening Program is also slated to be cut. Linda Blackford of the Lexington Herald-Leader reports that this UK program offers free vaginal ultrasound screenings to women for ovarian cancer and has provided nearly 50,000 free screenings since its creation 30 years ago.

Blackford notes that the Pediatric Cancer Research Trust Fund, established in 2015 by Sen. Max Wise, R-Campbellsville, has been approved to receive $2.5 million in each year of the biennium to fund pediatric brain cancer research at UK and U of L. Bevin's budget calls for each of the universities to provide a minimum of $1.2 million a year for the program.

Radiology and breast-imaging doctors make a case for annual mammograms starting at age 40; other groups' advice varies

Centers for Disease Control and Prevention photo

Kentucky Health News

A recent study found that younger women of breast-screening age are more likely to develop aggressive breast cancers than older women, which reinforces the American College of Radiology and the Society of Breast Imaging's recommendation for annual mammograms starting at age 40.

“Aggressive cancers in women in their 40s must be identified early to be effectively treated. Letting these tumors grow even one extra year before screening greatly increases odds that the woman will die from breast cancer. Women 40 to 49 should be screened regularly,” Dr. Debra Monticciolo, chair of the American College of Radiology Breast Imaging Commission, said in a news release.

Other groups have somewhat different advice. The recommendations of the U.S. Preventive Services Task Force are that average-risk women who are 50 to 74 years old should have a screening mammogram every two years, and that average-risk women who are 40 to 49 should talk to their doctor about when to start and how often to get a screening mammogram.

The American Cancer Society recommends women with an average risk of breast cancer should begin having yearly mammograms at age 45, and can start having them every other year beginning at age 55. It adds that women should be able to start the screening as early as 40 if they want to.

The ACR, SBI, American Congress of Obstetricians and Gynecologists, National Comprehensive Cancer Network and others recommend that women start yearly mammograms at 40, says the radiology college's news release.

The college disputes the claim that mammogram results in overdiagnosis, citing a British Medical Journal study based on direct patient data that found overdiagnosis in about 2 percent of cases, which the college said fits with the American Cancer Society findings.

The college's news release says overdiagnosis is likely between 1 percent and 10 percent, largely due to condition called ductal carcinoma in situ, a noninvasive cancer that is often treated to avoid the potential development of an invasive cancer.

The college argues that concerns about "overdiagnosis, survival and screening versus treatment effectiveness" are "based on assumptions, many of which are unsupported, rather than direct patient data and should not affect breast cancer screening policy."

It also points to  two large studies that  found women who get regular mammograms cut their breast-cancer death risk in half, and that annual screenings have more live-saving benefit than biennial screenings for every age group.

Since the 1980s, when mammograms became widely done, the U.S. breast cancer death rate, which had been stable for decades, has dropped 38 percent as more cancers are found early, the release says.

The National Cancer Institute says about 12 percent of women in the United States today will develop breast cancer at some time in their lives, which means that if the current rate stays the same, a woman born today has about a one in eight chance of being diagnosed with breast cancer in their lifetime.

“Giving the second-leading cancer killer in women a head start through reduced or delayed screening can be lethal for these women. Starting screening at age 40 remains the best policy,” Dr. Wendy B. DeMartini,  president of the Society of Breast Imaging, said in the release.

The Lannin and Wang study was published in the June 8 New England Journal of Medicine.

Legislature passes bills to name caregivers, help smokers quit; could still pass dense-breast notice and student-concussion bills

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Kentucky lawmakers have passed bills this year to make sure someone knows how to care for you when you leave a hospital, expand the role of pharmacists, increase access to smoking cessation, and offer some hope to terminally ill patients, among other health-related measures.

The bills now await Gov. Matt Bevin's signature or veto. Legislators will reconvene March 29 and 30 to reconsider any bills he vetoes; they could also pass additional legislation, but it would be subject to a veto without the opportunity for a override. Now that both houses of the General Assembly are controlled by the governor's party, such eleventh-hour legislation may be more likely.

Health bills that have passed

The "Kentucky Family Caregivers Act," Senate Bill 129, would require hospitals to record the name of a lay caregiver when a patient is admitted, notify that person when the patient is moved or discharged, and instruct the caregiver on the medical tasks he or she will need to perform when the patient goes home. The patient can decline this request. The bill, sponsored by Sen. Paul Hornback, R-Shelbyville. passed unanimously through both chambers and awaits the Governor's signature.

AARP, which supports this legislation, estimates that there are 650,000 family caregivers in Kentucky who save the state around $7 billion a year in health-care costs. AARP said in a statement that the bill will save even more money by improving post-discharge outcomes, reducing hospital readmissions and better allowing Kentuckians to recover at home, where they want to be.

The "Right to Try" bill, SB 21, also awaits the governor's signature. Sponsored by Sen. C.B. Embry Jr., R-Morgantown, it would make it easier for terminally ill patients to use experimental treatments. Terminal patients would be able to try drugs that have successfully completed the first phase of clinical trials but have not yet been approved by the U.S. Food and Drug Administration, with appropriate documentation from their health-care provider and approval of the drug company. The bill passed unanimously through the Senate and cleared the House 87-7.

"Right to Try" legislation has passed in 33 states and has been introduced in Congress, and has the support of Vice President Pence, Bloomberg News reports.

Kentucky lawmakers passed two bills that would expand the role of pharmacists.

SB 101, sponsored by Sen. Julie Raque Adams, R-Louisville, would allow pharmacists to administer all age-appropriate immunizations to minors aged 9 to 17. Current law allows pharmacists to administer flu vaccines starting at age 9, but for all other vaccines, pharmacists can only administer to minors starting at age 14. This bill unanimously passed both chambers and awaits the governor's signature.

SB 205, sponsored by Sen. Stephen Meredith, R-Leitchfield, would allow pharmacists to dispense a 90-day-supply of a non-controlled maintenance drug, such as those for blood pressure or high cholesterol, unless the prescription provides to the contrary. The bill passed unanimously in both Chambers and awaits the governor's signature.

Only one bill aimed at decreasing the state's high smoking rate has passed this session. SB 89, sponsored by Adams, would require all Kentucky health plans, including Medicaid, to provide barrier-free access to any smoking-cessation treatments approved by the U.S. Preventive Service Task Force. Some insurance companies have barriers to treatment, such as co-payments and prior authorizations. Bevin signed the bill March 21.

Health bills unlikely to pass

SB 78, which would have made Kentucky's schools 100 percent tobacco free, passed the Senate but couldn't get enough support among Republicans who control the House to be brought up in committee.

Two other bills aimed at protecting the health of children made no headway: House Bill 252, which would require an automated external defibrillator in every school; and HB 122, which would require children up to the age of 12 to wear a bicycle helmet.

Three bills that would increase the state's access to health-care providers also did not pass this session. SB 158 would repeal the requirement for nurse practitioners to work under a collaborative agreement with a physician to prescribe narcotics and some other controlled substances, and for the first four years of prescribing other drugs. HB 19 and SB 55 would have permitted physician assistants to prescribe and dispense controlled substance. The bills may have been hamstrung by the state's epidemic of opioid abuse.

Another bill that is dead this session is Senate Bill 108, dubbed the "Palliative Care" bill. This bill passed the Senate unanimously, but Rep. Addia Wuchner, chair of the House Health and Family Services Committee, says it needs more work. The bill's aim is to use training and education to increase access to palliative care, which is aimed at providing the best quality of life possible for patients with chronic or terminal diseases.

Health bills that could pass

One health bill likely to pass in the final two days is HB 78, which would require providers of standard mammograms to inform patients if they have "dense breast tissue" when appropriate, because such tissue can hide cancers. The notice would allow patients who have dense tissue the opportunity to determine with their provider if they need further screening.

Almost 40 percent of women have dense breast tissue, and some men do. They are twice as likely to develop breast cancer, Rep. Jim Duplessis, R-Elizabethtown, the bill's sponsor, said at the bill's hearings. The Dense Breast-info website says 27 states require some level of breast density notification after a mammogram. The bill passed unanimously through the House, passed a Senate committee and is before the full Senate.

Another bill that could pass would prohibit a coach from playing a student-athlete who has been diagnosed with or is suspected of having a concussion without written clearance from a physician. House Bill 241, sponsored by Rep. John Sims, D-Flemingsburg, passed unanimously in the House, passed a Senate committee and is before the full Senate.

This story was updated March 22.

About 3/4 of the Kentuckians getting free exams and screenings via Medicaid are covered by its expansion, study finds

More than three-fourths of the Kentuckians who got free medical screenings through Medicaid last summer were covered by the expansion of the program under the Patient Protection and Affordable Care Act, according to a study done for the Foundation for a Healthy Kentucky.

Likewise, almost three-fourths of Medicaid substance-abuse treatments were for people included in the expansion of the program to people with incomes up to 138 percent of the federal poverty level, $16,394 for an individual or $33,534 for a family of four.

Medicaid covered more than 44,000 dental exams, 10,143 screenings for breast cancer, 6,319 colorectal cancer screenings, 6,153 hepatitis C screenings and 4,495 diabetes screenings for non-elderly Kentucky adults during July, August and September 2016. It also covered 7,039 births, 22 percent of which were for for expansion patients.

"The dramatic growth in preventive health screenings for low-income Kentucky adults is one of the most meaningful benefits of Medicaid expansion in Kentucky," said Ben Chandler, CEO of the foundation. "Getting recommended tests such as colorectal cancer screenings, mammograms or dental exams gives Kentuckians the chance to either prevent chronic disease or get earlier treatment. These screenings can quite literally save lives. They can also lead to significant savings for Medicaid and other programs that pay the cost of caring for Kentuckians who otherwise would put off medical visits and just get sicker."

Since the Medicaid expansion began in January 2014, people covered by it have had 224,720 dental exams, 15,692 screenings for diabetes, 59,529 breast cancer screenings, 38,190 colorectal cancer screenings, 24,157 hepatitis C screenings and 53,465 substance-abuse treatments, according to the study by the Health Access Data Assistance Center at the University of Minnesota.

Study finds Kentuckians on Medicaid expansion make heavy use of preventive screenings

Kentuckians covered by Medicaid through its expansion in 2014 are using their preventive screening benefits more than the traditional Medicaid population, according to a report done for the Foundation for a Healthy Kentucky.

"One of the benefits of getting more people insured is that they take advantage of the preventive services that can lead to improved health and lower health care costs in the long run," Ben Chandler, president and CEO of the foundation, said in a news release. "That positive trend is what we're seeing in Kentucky in terms of breast and colorectal cancer screenings, preventive dental services and diabetes and hepatitis C screenings for Kentuckians with low incomes."

These findings come as no surprise, since those who qualify for Medicaid under the expansion (to those who earn up to 138 percent of the federal poverty line) often work at low-paying jobs that don't provide health insurance, are students or are caretakers and have gone without health insurance for a long time.

Since the implementation of the Patient Protection and Affordable Care Act and the state's expansion of Medicaid, Kentucky's uninsured rate has dropped by more than half, from 14.3 percent in 2013 to 6 percent in 2015 respectively, according to the report.

One of the 10 essential benefits of the reform law is free preventive health care, a benefit that thousands of Kentuckians have taken advantage of.

The study found that in the second quarter of 2016, Medicaid paid for 9,848 breast cancer screenings, with 87 percent of them (8,500) for Kentuckians covered by the expansion. The other 1,251 screenings were for patients who qualified under traditional Medicaid.

This was similar to the same time frame last year, when 88 percent of the 10,191 breast screenings were for those covered by the expansion.

"Screenings for breast cancer among those living on lower incomes can be particularly important because, statistically, low-income women have a higher risk of not being diagnosed until the later stages of breast cancer," Chandler said. "If doctors can catch the cancer early with regular mammograms so patients can get treatment at the earlier stages, we're talking about saving lives while also reducing long-term costs."

MEDICAID DATA BY QUARTER, January 2015 through June 2016

Foundation for a Healthy Kentucky graphic on Medicaid preventive services in Kentucky

This trend of increased screenings by the expansion population also held true for other screenings during the second quarter: 88 percent of the 6,289 colorectal cancer screenings; 79 percent of the 4,589 diabetes screenings; and 65 percent of the 5,820 hepatitis C screenings.

The report also found that Medicaid covered 43,463 preventive dental screenings between April and June and that 76 percent, or 32,968, were for expansion patients.

"In my experience, Medicaid expansion patients first used their plans at the dentist to address dental neglect in hopes of eliminating pain and getting prepared for the workforce. It is very difficult to concentrate in school or at work with a toothache," Laura Hancock Jones, chair of the Kentucky Oral Health Coalition and a member of the foundation's Community Advisory Committee, said in the release.

Medicaid has also seen a big jump in substance-abuse treatment, from 5,675 services during the first quarter of 2015 to 15,234 during the second quarter of 2016, says the report. More than 56,600 substance-abuse treatment services have been covered by Medicaid in those 18 months.

Mental-health benefits and the treatment of substance-abuse disorders are also benefits required under federal health reform.

"Substance abuse is one of the most critical health and safety issues facing Kentuckians," Chandler said. "Overdose deaths continue to climb, and addiction exacts a terrible emotional, financial and physical toll on families."

Medicaid also covered 6,620 births, 1,769 of which were delivered by expansion patients, during the second quarter of this year.

The report comes from the State Health Access Data Assistance Center at the University of Minnesota, which the foundation is paying more than $280,000 to study the impact of the Patient Protection and Affordable Care Act over three years.

Kentucky's health rankings are poor in just about every category,  with some of the highest rates of cancer, diabetes, obesity, stroke and heart disease in the nation. Health advocates look for improvements in these rankings to come from long-term preventive care, which many now have because of health reform and the expansion.

But health advocates and many Kentuckians on Medicaid are concerned about what will happen to these benefits if the state's Medicaid program is changed, as Gov. Matt Bevin has proposed, or health reform is repealed, as President-elect Donald Trump has promised.

Bevin says the state can't afford to have nearly one-third of its population on Medicaid and has submitted a proposal to the federal government to let the state require beneficiaries to pay monthly premiums and require non-disabled recipients to work or to do community service. It also requires some of the currently covered benefits, like vision and dental, to be earned through a rewards program. The plan is currently under negotiation with federal officials.

The expanded population is paid in full by the federal government through the end of this year. In 2017, the state will be responsible for 5 percent of the cost, rising in annual steps to the reform law's limit of 10 percent in 2020. Bevin's proposal says this plan "is expected to save taxpayers $2.2 billion over the five-year waiver period," by reducing enrollment in the program, but only $331 million of that would be state tax money, because the federal government covers the bulk of Medicaid costs.

President-elect Donald Trump and the GOP-controlled Congress have promised to repeal health reform, though Trump has said insurance companies should still have to cover pre-existing conditions. Republicans in Congress have long wanted to turn Medicaid into a block-grant program, largely run by the states.

Kentucky ranks first in deaths from cancer, a longtime fact given big play on the Sunday front page of The Courier-Journal

Kentucky has led the nation in cancer deaths for several years, but that fact hasn't been trumpeted on the front page of a major newspaper in quite the way The Courier-Journal did Sunday, publishing a long story by Laura Ungar that explains the problem in the state and ways to address it.

"The biggest culprit is lung cancer, which strikes and kills Kentuckians at rates 50 percent higher than the national average," Ungar writes, noting the state's high smoking rate. "But Kentucky’s death rates also rank in the Top 10 nationally for breast, colorectal and cervical cancers."

“It’s really been driven by three major things: obesity, smoking and lack of screening,” Louisville gastroenterologist Dr. Whitney Jones told Ungar. “Our state is completely inundated with risk factors.”

How most states rank in cancer deaths (C-J chart)

Other causes include poverty and limited education among many Kentuckians. That makes them less likely to be screened for cancer, and more likely to die from it because it is discovered too late. "Federal figures analyzed by the American Cancer Society show 46.8 percent of Kentucky women 40 and older got a mammogram and clinical breast exam in the past year, compared with around 60 percent in states with the best rates," Ungar writes.

Efforts to increase screening have had the most success against colon cancer. Since the Colon Cancer Prevention Project started 11 years ago, "The screening rate has more than doubled to 69.6 percent, and colorectal cancer deaths are down more than 25 percent statewide," Ungar notes.

A screen for lung cancer has been developed only recently, "and today’s preventive low-dose CT scans for longtime smokers are far less routine than tests like mammograms or colonoscopies and are not always covered by private insurance," Ungar reports.

While smoking is generally blamed for lung cancer, the disease can also be caused by environmental factors, and "up to 20 percent of those who succumb to lung cancer are non-smokers," Ungar notes. "The risk of lung cancer is much higher for smokers exposed to carcinogens such as radon, asbestos, arsenic or chromium. The U.S. Environmental Protection Agency classifies a wide swath of Central Kentucky as having the highest potential for indoor radon gas, the second-leading cause of lung cancer." Research has shown high rates of arsenic and chromium in Appalachia.

"Shortages of doctors and cancer screening and treatment facilities make things even worse," Ungar reports. "A workforce capacity study conducted for the state by Deloitte Consulting in 2013 found that Kentucky needed 3,790 more doctors just to meet pre-ACA demand and would need many more by 2017. Complicating matters, rural Kentuckians often live long distances from specialists and cancer centers, and may face transportation problems as well. . . . The longer the drive to medical facilities, the later cancer is diagnosed."

E. Ky. women pass up breast, cervical cancer screenings due to embarrassment, misinformation; fatalism may play a role

Appalachian Kentucky women often don't get available screening test for breast and cervical cancer because of embarrassment, lack of accurate information about availability and guidelines, and lack of encouragement from their doctors to get these test, University of Kentucky researchers have found.

The study also found that Appalachian women who never or rarely get mammograms, which screen for breast cancer, usually don't get pap-smears, which screen for cervical cancer, either, Allison Perry reports for UKNow.

Appalachian Kentucky has a 17 percent higher overall cancer death rate than the rest of the country, with a 67 percent higher incidence of invasive cervical cancer and a 33 percent higher death rate of invasive cervical cancer. Breast cancer is the 3rd leading cause of cancer in Kentucky.

Researchers talked to 222 women in six rural counties in Appalachian Kentucky to assess whether they followed cancer screening guidelines. The study, published in the journal Women & Health, found that 33 percent of the women had recently been screened for both breast and ovarian cancers and 48 percent were rarely or had never been screened for both.

The study also found four common reasons that would increase the odds that these women would never or rarely get screenings for breast and cervical cancer: embarrassment to get the test, a belief that not having insurance makes it difficult to get a Pap test, belief that a mammogram is only necessary if you have symptoms and lack of advice to get a mammogram from their doctor in the prior 12 months, Perry reports.

The belief that breast cancer screening is only necessary if a woman has symptoms is of particular concern to the researchers, Perry reports. Often, by the time a woman has symptoms or has a lump, the cancer has advanced. Women 40 and older should get a mammogram every one to two years. If all did, that could reduce the mortality rates by 20 to 25 percent over a decade, Perry reports.

"Our study findings reinforce the challenges to screening faced by many vulnerable and underserved women," said Nancy Schoenberg, lead author on the paper and professor of behavioral science at the UK College of Medicine, told Perry. "Whether they experience inadequate knowledge, as shown in this research, or inadequate resources, as shown in other studies, many women find it difficult to obtain optimal preventive health care. Facilitating optimal prevention will reduce the huge toll cancer takes on women, their families and their communities."

In an earlier paper, in Medical Anthropology Quarterly, Schoenberg and Elaine Drew of the Medical College of Wisconsin challenged the longstanding notion that fatalism (the belief in a lack of personal power or control over destiny or fate) discourages Appalachians from modifying their health behaviors. Their studies of rural Appalachian women’s health decisions surrounding cancer treatments "suggested that for these women, numerous and complex factors—including inadequate access to health services, a legacy of self-reliance, insufficient privacy, combined with a culturally acceptable idiom of fatalism—foster the use of, but not necessarily a rigid conviction in, the notion of fatalism," the study report says.

New technology at UK allows for more comprehensive breast imagery, especially for women with much dense or fatty tissue

Technology that will enable radiologists to see individual breast structures without overlapping tissues obstructing their view will begin being used at the breast care center at the University of Kentucky Markey Cancer Center. It will be the only center in the state to use the 3-D technology known as tomosynthesis.

"In addition to providing the traditional top and side images of the breasts taken during a regular mammogram, tomosynthesis also allows the technician to take multiple X-ray pictures of each breast from many angles," a UK press release said. "A computer than combines all this information into one 3-D image."

The technology is expected to be especially useful for women who have dense or fatty breast tissue. More than 50 percent of women under the age of 50 have dense tissue and more than 30 percent of women over 50 have dense tissue. (Read more)