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The Costa Rica Medical Marketplace

By Galya Gerstman – I often joke to outsiders that in Costa Rica, it would appear that traffic regulations are not obligatory, but merely suggestions, judging by what I see on the roads. I have since found that this flexible attitude toward what would normally be considered serious matters seems to extend to other areas as well. I will give you a case in point.

I have a friend, let’s call her Maria, who is a lawyer. Her specialty is contract negotiations, and so I must assume that she is a pretty deft negotiator. Why am I telling you this? Be patient.

Well, Maria went for her yearly mammogram and the doctor discovered a mass. That’s not a very funny intro, but what is funny is all that transpired after. She then went to an oncologist who sent her off to do an MRI and a biopsy. There’s something else you should know about Maria: she’s one of those tree-hugger types. You know, vegetarian (except when it comes to The Cheesecake Factory’s Shrimp Scampi), makes herself a tea when she has a headache instead of taking aspirin, didn’t let her kids watch TV till they were, like, in high school, etc. So she wasn’t overly thrilled at the idea of putting her body through these tests. Moreover, she told the oncologist, she had had the same mass 2 years ago and a biopsy at the time had shown a negative result. He was not convinced.

“That was a fine needle aspiration,” he explained, “and those are at best 60% accurate.” This was news to my friend, as well as to the doctor who had sent her for the first biopsy and the one who had performed it, she surmised. But the present doctor’s convincing demeanor forestalled her protests. “The core biopsy, on the other hand, gives us a bigger sample, and thus more accuracy.” Bigger sample meaning bigger needle? She gulped.

So first she endured the MRI, in which she was encapsulated in a big metal tube and told not to move an inch—for thirty whole minutes—while the machine banged out noise like your sixteen-year-old’s garage band. Even with the noise-obstructing headphones, she still heard the clanking and whirring, as if the Wizard of Oz’s tin man were doing a Zumba class. But the worst was not being able to move for thirty whole minutes. She was sure she would suddenly sneeze or have one of those spaz attacks where your whole body shudders, and have to repeat the process again.  And did I mention the price? Eight hundred dollars. Private medicine, of course. Otherwise she’d probably have had to wait two years for the Costa Rican Social Security to fit her in. But anyway, she was in luck. They were having a sale! I didn’t know medical procedures could be marked down (was it a slow season?) but indeed, for all that month, there was a sale on MRIs, so she only had to fork over five hundred.

After that she had the core biopsy, wherein the doctor and nurse had to give her five mammograms until they found the spot to gouge. “Isn’t all that radiation from the mammograms dangerous?” she worried. The nurse assured her it was less than the radiation one is exposed to on a transatlantic flight. Maria hadn’t known about radiation on planes. Now she had yet another thing to worry about next time she flew to Madrid. Finally, they inserted a little titanium coil there after they were done, so that for her next mammogram they wouldn’t have so much trouble finding that damned spot again.

The diagnosis: Lobular Carcinoma In Situ. Well, like any self-respecting internet surfer, my friend quickly discovered that this is the most inoffensive type of tumor you can have. “In Situ” means it’s “in place”, in other words, not spreading. The Cancer.org site began thusly: “[Blah blah blah] but it differs from DCIS in that it’s not a pre-cancer. The main difference is that LCIS cannot become an invasive cancer, even if it isn’t treated.” And furthermore: “Since LCIS is not a true cancer or pre-cancer, often no treatment is recommended.” My friend was, as one might expect, overjoyed.

Until she went back to her friendly neighborhood oncologist. “That doesn’t mean it doesn’t have to come out,” he corrected her. In fact, the MRI seemed to show some very small but nonetheless suspicious masses that it would be best to remove, he advised. Moreover, he suggested removing the original mass as well as ten centimeters around it, and also injecting a substance the day before to see if it had spread to the lymph nodes or was capable of spreading to them and if so, he would take out part of the underarm as well. The man was nothing if not thorough!

Maria left his office shrunken with fright. If she had been traumatized by the MRI which was not even invasive, and the core biopsy which was only a very thick needle, she was positively quaking at the thought of surgery and its aftermath. For though the doctor had told her it was a simple procedure (for him) (she hoped to God), and that she wouldn’t even have to spend the night in the hospital, he also mentioned in passing radiation and possible chemotherapy treatments afterwards. Having seen the effects of chemo on various people before they died anyway, my friend was understandably frightened.

She decided to get a second opinion. The second oncologist she consulted was equally lauded for being a specialist. Nonetheless, after hearing stories of acquaintances’ radical double mastectomies, my friend was in a bad state. By the time Maria sat down in front of the new doctor, she was like the cowardly lion (again from the Wizard of Oz! My childhood exposure to culture was limited)—shaking and stuttering. And, doing the lion one better, hyperventilating to boot.

But this doctor gave her good news. MRIs are very detailed, true, she said. But with so many little dots and spots, it’s easy to mistake something benign for a tumor. As for the main tumor, the LCIS, however, she was of much the same opinion as the first doctor: surgery, radiation and possibly chemo. She even agreed with the armpit removal.

By now Maria had calmed down a bit, and regained some of her lawyerly wherewithal.  “Look,” she complained. “I’m hardly a B-cup as it is. You take out 10 centimeters [4 inches!], and I’ll look like an empty hot water bottle!”

“Well, I don’t think we have to take out 10 centimeters,” the doctor agreed. “I’m sure we can get away with 1 centimeter.”

“Now that’s more like it,” my friend began. “That, I can live with, no pun intended. But what’s this about removing my armpit?”

“I wouldn’t necessarily have to remove it. You get a substance injected into the area which will cling to the parts that are susceptible to be invaded by the tumor.”

“But you said the tumor was non-infiltrated. Not spreading.”

“Yes.”

“So why test for seeing if it would move toward the lymph nodes?”

“Well, that’s the usual treatment.”

“But—“

“But okay. Never mind. There’s very little probability of it spreading, you’re right.”

“Good.”

“We’ll just perform the surgery and then you’ll either do the post-operative treatments—“

“You’re talking about chemotherapy, aren’t you?”

“Well, that’s sometimes warranted…” My friend made a face. “…but as your tumor is really not a cancer, I guess we can skip that.”

Maria’s face brightened. “Great! Whew! I was really scared of that!”

“OK, then, fine. No chemo. Just radiation.”

“Uh, radiation?”

“Yes, either you do something like ten post-operative treatments for about an hour each time over the course of several weeks, or I give you one strong and concentrated blast right over the area after I’ve opened you up and removed the tumor. Your choice, but I would recommend the concentrated blast, since it’s a one-time thing.”

“Well, doctor, I really don’t like the sound of either. I mean, doesn’t radiation itself cause cancer?”

“Well, yes, but sometimes it’s necessary to remove any remaining cancer.”

“But you said it’s not invasive cancer. You said it’s not even considered cancer.”

“True, but in the future it could develop…”

“I really, really don’t want to have radiation.”

“Well, okay, then. I guess you have a point. Since it’s not spreading, I suppose we can forego the radiation. I guess you can get away with just taking an estrogen-blocker.”

“Um, you’re referring to Tamoxifen, right?”

“Yes, that’s one type.”

“Well, doctor, I read that that drug can cause endometrial cancer.”

“In very rare cases.”

“I’m not a betting woman.”

“Well, there is a new type of estrogen-blocker…”

“Look, doctor. Now, I know you might think I’m one of those crazy all-natural types, but I’ve been doing a lot of research into alternative medicine. I’ve read about all kinds of different treatments that, although not approved by the FDA (and everyone knows those guys are in the pockets of the medical and pharmaceutical lobbies),” my friend said to her doctor, straight-faced, “have cured lots of people!”

“Such as?”

“Oh, there’s just loads. Intravenous vitamin C treatments, vitamin B-17 which is extracted from apricot kernels, selenium pills, the Budwig protocol which is a mixture of cottage cheese and flaxseed oil…” Seeing the doctor’s face, she found it prudent to leave out the coffee enemas.

“I have never heard of most of what you just mentioned,” the doctor responded, stone-faced, “except for the intravenous vitamin C which is a beauty treatment.” A beauty treatment? Who’d be crazy enough to spend a half hour with a throbbing needle in his or her vein? Wait, what? If people are willing to go through surgery or have needles stuck between their eyes for purely aesthetic reasons, then why not intravenous vitamin C?

“Okay, look, doctor,” my friend made her pitch. “If, as you say, what I have is a non-cancer, and if, as you yourself said, it hasn’t changed since the first biopsy two years ago, let’s do this: give me six months to do some of the treatments I’m telling you about, and if in six months it hasn’t changed, then I’ll do what you say and go under the knife.”

The doctor sighed. “Fine. If that’s what you want. But not six months. Three.”

“Three, fine. Three is okay.”

“All right then. After three months from now, you’ll get a mammogram… Now what?”

“How about just an ultrasound? You know there’s new research saying that mammograms might actually cause cancer—“

“All right! Ultrasound instead of mammogram!”

In fact, my friend was already scheming to postpone the surgery indefinitely if the tumor didn’t change, at the price of an ultrasound every three months, if need be.

It would seem that in Costa Rica, you can bargain over anything.