Orientation at Arkansas Tech University this year included a surprising topic for a Bible Belt state that pushes abstinence-only in high school. Every freshman was shown a newly produced video in which real students talk about the struggle of an unplanned pregnancy, and the challenge of staying in school as a parent.

“I lost a lot of friends,” says one young woman in the video who had dreamed of becoming a surgeon. A young man says he “went from not having any responsibility to having a full-time responsibility,” while another laments that Friday nights are no longer spent with friends but at home “watching Dora. A lot of Dora.”

The message is clear, and it will come up again throughout the year: in a college success course, in group chats in dorms, at a slew of events during Sexual Health Week.

Why in college? Arkansas has the nation’s highest rate of teen births, but most of them — here and nationally — are actually to young adults, 18 and 19 years old. Last year, the Arkansas Legislature passed a law directing the state’s public colleges and universities to tackle unplanned pregnancy. Schools have each been crafting their own plans for how to do that, and they launched the effort during orientation this month.

After watching the video at one session at Arkansas Tech in Russellville, nearly every student said it hit home.

“I think there was anywhere between five to 10 girls in my grade that got pregnant,” says freshman Sydney Blackwell. “I remember in eighth grade there was a girl that never made it to ninth grade because she got pregnant.”

Only 4 of 20 students in this group say they had sex ed in high school. Brooklynn Evans says she didn’t get much guidance at home, either, not even the basic birds and bees. “My parents were too uncomfortable to talk about it,” she says.

Same with Carlos Morales. He thinks it’s great that his college is bringing this up, but “it would have been better to have a class earlier, during our middle school.”

‘The problem in the room that nobody wants to discuss’

Arkansas’ law is modeled on one that took effect last school year in Mississippi. Both had bipartisan support and were amazingly uncontroversial.

“It was surprisingly easy; it shocked me,” says Rep. Deborah Ferguson, the Democratic co-sponsor of the Arkansas law. Still, she says it would not be politically possible to mandate sex ed in earlier grades. The legislation’s Republican co-sponsor believes that’s best left to local districts.

But that co-sponsor, Rep. Robin Lundstrum, had an early job in family planning. She says she heard from high school students over and over that they had nowhere to turn for information on how to not get pregnant. “It’s the problem in the room that nobody wants to discuss,” she says.

At Arkansas Tech, student wellness dean Kristy Davis says it makes sense to target those in college, many of whom are away from home for the first time. She says faculty can help “make sure that they’re prepared and they have the information to make good decisions for themselves.”

The mandate is so far unfunded. Angela Lasiter, a program specialist with the Arkansas Department of Higher Education, is creating a nonprofit and hopes to attract money to keep the effort going. At community colleges, which usually lack a health center, she’s also making sure nearby clinics are stocked with the most effective contraceptives. A substantial share of students at some two-year colleges are already parents, and Lasiter says the state’s push can help prevent them from having a second child.

Some universities are even weaving the topic into their curriculum. Lasiter says it’s easy to drop into classes like statistics, English, “or, say, Speech 101. ‘We would like for you to write a 10-minute speech on how to prevent unplanned pregnancies.’ Boom.”

The goal, she says, is to get students talking. And if they also talk with their little sisters and brothers, all the better.

There’s also a broader benefit for the state, Lasiter says. When young parents drop out of college, or never get there in the first place, it costs Arkansas $129 million a year in “lower income, more people on welfare, a less higher quality of living.” That economic hit is compounded because the children of teen mothers are more likely to have an early, unplanned pregnancy themselves.

But is college too late to teach sex ed?

Magical thinking

“They don’t know as much as they think they do, and they don’t know as much as we wish they did,” says Andrea Kane, vice president for policy and strategic partnerships at the National Campaign to Prevent Teen and Unplanned Pregnancy. She says research shows young adults think they know how to not get pregnant, but when pressed for details they’re prone to myths and misinformation. For instance, she says, “4 in 10 young adults in this country believe it does not matter if you use birth control or not; when it is your time to get pregnant, you will.”

The National Campaign has been pushing for more prevention efforts at the college level, and Kane says other states are showing interest in the new laws in Arkansas and Mississippi. She says even students who had sex education in high school might have forgotten the information, or may find it more relevant now that they’re older.

Marie Sandusky has been counseling students at the University of Arkansas at Little Rock since well before the state’s law. She directs health services there, and says it’s a challenge to help students understand the risk of pregnancy.

“There’s this 18- and 19-year-old brain thing that’s kind of like magical thinking,” she says. “Sort of like, ‘It’s not going to happen to me.’ “

With the new law, the university is being more proactive. This year, incoming freshmen had to complete an online lesson on preventing unplanned pregnancy. In their dorm rooms, they found a postcard with the health services phone number and the tag line, “Plan to postpone parenting.”

Enlarge this image

Marie Sandusky directs student health services at the University of Arkansas at Little Rock. In an orientation session, rag dolls are handed out to symbolize the number of students who will become parents this year if they don’t practice safe sex or use birth control. Jennifer Ludden/NPR hide caption

toggle caption Jennifer Ludden/NPR

Sandusky also drove home the risk factor at a recent orientation event. In an auditorium of 300 students, 22 of them found a red star under their seat. They received a rag doll on a string that they had to wear around their neck the rest of the evening. “And then we say, ‘If you choose to become sexually active, and don’t choose to practice safe sex or get on birth control,” says Sandusky, “this many people will have a baby by the end of the year.’ “

Of course, the hope is that Arkansas’ push to prevent unplanned pregnancy will eventually bring down that number.

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The EpiPen, an injectable drug that reverses severe allergic reactions, just got a little cheaper for some consumers.

The device’s manufacturer, Mylan NV, announced Thursday that it will offer coupons worth as much as $300 off a two-pack.

The move is a reaction to harsh criticism from consumers and several lawmakers over repeated price increases that have boosted the cost of the medication to more than $600 from less than $100 just a few years ago.

The company says it will offer the discounts to patients whose insurance doesn’t cover the costs because of high deductibles or limited pharmacy benefits.

But coupons may not be enough to tamp down anger over the price hikes.

“This step is much more a PR fix more than a real remedy,” Sen. Richard Blumenthal, D-Conn., said in an interview Thursday. “What’s needed is robust, real action to lower the price for everyone, not just a select few.”

He says the EpiPen has such enormous market share that the company may be violating antitrust laws by exploiting that. A report by the health care website Stat says some of Mylan’s contracts to give schools free or discounted EpiPens may have done just that, because they bar the schools from buying competitors’ products.

Mylan told Stat that the provision restricting school purchasing has since been discontinued, but did not say when it was halted.

Blumenthal is just one of several lawmakers who have called for investigations into Mylan’s business practices and have asked for justifications of its price increases in recent days. He and a few others say the discounts aren’t enough.

Blumenthal sent a letter to the company earlier this week demanding that it lower the price.

Sen. Charles Grassley, R-Iowa, sent a letter to Mylan demanding an explanation for the increase. And Sen. Amy Klobuchar, D-Minn., has asked the Federal Trade Commission to investigate whether Mylan has violated antitrust laws in its marketing of the EpiPen.

Rep. Elijah Cummings, D-Md., says his Oversight and Government Reform Committee would hold hearings. “Offering a meager discount only after widespread bipartisan criticism is exactly the same tactic used by drug companies across the industry to distract from their exorbitant price increases,” Cummings said in a statement.

And Democratic presidential hopeful Hillary Clinton weighed in on her Facebook page. “It’s wrong when drug companies put profits ahead of patients, raising prices without justifying the value behind them,” she wrote.

The wholesale price of a single pen was about $47 in 2007. It rose to $284 this summer, according to Richard Evans, a health care analyst at SSR. But consumers can no longer buy a single pen, so the retail price to fill a prescription today at Walgreens is about $633, according to GoodRX.

Blumenthal says a solution could require new laws.

“At the end of the day there may need to be stronger legal protections against these types of price gouging and profiteering at the expense of people who need a lifesaving drug where the company has a stranglehold on the market,” he says.

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A major study about the best way to treat early-stage breast cancer reveals that “precision medicine” doesn’t provide unambiguous answers about how to choose the best therapy.

“Precision doesn’t mean certainty,” says David Hunter, a professor of cancer prevention at Harvard’s T.H. Chan School of Public Health.

That point is illustrated in a large study published Wednesday in the New England Journal of Medicine, involving decisions about chemotherapy.

As is true for many cancers, breast cancer responds best to treatment when it is caught early, before it has spread throughout the body. Dr. Fatima Cardoso, the study’s lead author and a breast cancer specialist at the Champalimaud Clinical Center in Lisbon, Portugal, says that creates a conundrum for doctors and patients alike.

Because it’s the only opportunity to cure the cancer, “when in doubt we tend to treat” women with early-stage breast cancer, she told Shots. “So we know that we overtreat the patients with early breast cancer.”

That means that women could end up undergoing chemotherapy even if it wouldn’t really improve their survival odds.

Hoping to refine those treatment decisions, Cardoso helped organize a huge study throughout Europe to see whether a commercially available genetic test called MammaPrint could help reduce that overtreatment. More than 6,600 women participated at 112 institutions in nine nations.

Scientists identified women with breast cancer whose physical exams suggested they were at relatively high risk for having the cancer return eventually after surgery, but who seemed to be at low risk of recurrence based on the genetic test results.

They were invited to participate in the study, which would randomly assign them to have chemotherapy or not. “You know that chemotherapy is a treatment that scares people, so overall and for the majority of patients, it was not difficult to convince them,” Cardoso says.

The genomic test, which studies 70 distinct features of a tumor, did a pretty good job of predicting who was at low risk for recurrence of breast cancer and could therefore avoid the pain, discomfort and risks of chemotherapy. (The test, priced at $4,200, is covered by some insurance in the United States.)

The scientists found that 46 percent of women who were deemed to be at high risk of recurrence based on physical symptoms could actually skip chemotherapy with little consequence to their long-term survival.

But the test results weren’t always definitive. About 95 percent of women who skipped chemotherapy as a result of the genetic test results were free of metastasis five years later, but those who had the additional treatment did about 1.5 percentage points better, give or take.

“It’s possible that the benefit is zero, and it’s possible that’s 2 percent or maybe even a little more, you can’t be sure,” says Dr. Clifford Hudis, chief executive officer of the American Society of Clinical Oncology. He was not involved in the European study but co-wrote an editorial accompanying it. It would take another huge clinical trial to figure out whether chemotherapy does in fact add a small survival advantage.

But the study raises a bigger point here: The genomic test, as precise as it is, offers only probabilities, not absolute guidance. And that’s a lesson that applies to the whole new realm of precision medicine, which is billed as potentially transformative for medical care.

“The new tools will definitely be helpful, but they often will pose challenges about what the right decision is,” says Hunter, who wrote a perspective piece noting that people will need to develop a tolerance for uncertainty when using precision medicine tests.

Is it worth all the trouble of chemotherapy for women who are found to be at low risk for recurrence in this genomic test? That’s a tough call, because it requires grasping the rather abstract idea of improving survival odds by maybe just 1 percentage point.

“As humans, we’re notoriously poor at assessing risk and making those calculations,” Hunter says.

He says doctors and patients need better tools to understand and communicate the subtleties that are inherent in precision medicine.

Cardoso is already seeing this play out in her clinic. Women shown to be at low genetic risk on the MammaPrint test are usually opting not to have chemotherapy after their surgery. “But there always [are] some patients for whom 1 percent benefit is enough — and you need to respect the wishes of each individual patient.”

She says the women clearly benefit from the new information, even though it doesn’t provide an absolute answer.

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