When It Comes to Cancer Screening, Are We All Nuts?

Washington-Post-LogoIn a recent Health Affairs article, David Asch and I wrote about how hard it can be to stop screening aggressively for things like breast and prostate cancer even when the evidence suggests we are doing more harm than good. Well, journalist Steven Petrow has a nice piece in the Washington Post looking at the good old testicular exam. Lots of nice insights, so I thought I’d share it:

Late last year, “Today” show anchors Willie Geist and Carson Daly took one for the men’s team when they underwent testicular cancer exams on live TV. Lots of predictable joking ensued, especially from co-anchor Savannah Guthrie, who ad-libbed: “When I heard what you guys were doing, I thought it was nuts!” The “attending” urologist, David Samadi of Lenox Hill Hospital in New York, also took to wordplay, asking: “Who’s going to play ball first?” Geist stepped up.
Within minutes both anchors received clean bills of health along with Samadi’s congratulations for getting the exams. Samadi also encouraged the rest of maledom to perform testicular self-exams monthly in the interest of early detection, which he said can save lives — but do they?
Nearly 9,000 cases of testicular cancer in the United States are diagnosed every year — especially among men ages 15 to 34, where it’s the most common cancer — so the “Today” segment seemed like a useful public service announcement.

But unfortunately there’s no evidence that self-exams detect testicular cancer at an earlier stage, according to Durado Brooks, director of colon and prostate cancer prevention programs for the American Cancer Society. Even if these exams did, says Kenny Lin, an assistant professor of family medicine at Georgetown University Medical Center, early detection has little, if any, bearing on outcomes for those who are diagnosed. Lin calls the “Today” segment “a stunt cloaked as a health message,” and he points out that even the august U.S. Preventive Services Task Force recommends against testicular cancer screening — a change from the past.

Other routine screening tests have also earned a thumbs down from the medical establishment in recent years, as more clinical evidence has been gathered showing them to be less beneficial than once thought. Among the tests no longer universally recommended: PSA screening for prostate cancer, breast cancer self-exams for women and mammograms for women younger than 50, and Pap smears for cervical cancer for women younger than 21. Not only do these exams have nearly no effect on outcomes, the task force said, they can sometimes do more harm than good.

Regarding testicular screening in particular, it “is unlikely to offer meaningful health benefits, given the very low incidence and high cure rate of even advanced testicular cancer” while “potential harms include false-positive results, anxiety and harms from diagnostic tests or procedures,” according to the task force.

So why do some doctors continue to recommend these screenings — and why do some patients still want them? (To read the rest of this article, please visit The Washington Post.)

You Thought Innovation Was Hard, How about De-Innovation?

HealthAffairsJournalDavid Asch and I recently published an article in Health Affairs on the challenge of getting healthcare practitioners to stop doing things they are accustomed to doing, even when the evidence that those things are harmful becomes overwhelming. Here is a teaser from that article, and a link to the full piece:

As hard as it may be for clinicians to adopt new practices, it is often harder for them to “de-innovate,” or give up old practices, even when new evidence reveals that those practices offer little value. In this article we explore recent controversies over screening for breast and prostate cancer and testing for sleep disorders. We show that these controversies are not caused solely by a lack of clinical data on the harms and benefits of these tests but are also influenced by several psychological biases that make it difficult for clinicians to de-innovate. De-innovation could be fostered by making sure that advisory panels and guideline committees include experts who have competing biases; emphasizing evidence over clinical judgment; resisting “indication creep,” or the premature extension of innovations into unproven areas; and encouraging clinicians to explicitly consider how their experiences bias their interpretations of clinical evidence.

Tobacco is Taking Over the World!

We’ve done a lot of things in the United States over the last few decades to curb tobacco consumption. We’ve warned people cigarettes will kill them, created persuasive ad campaigns to scare people away from cigarettes, and added a hefty tax to the product. As a result, cigarette use in United States is lower than it has been in decades. Which means one thing – to maintain profits, tobacco companies need to get people smoking elsewhere in the world. And their efforts seem to be coming to fruition, based on this picture from the Wall Street Journal, which I learned of through Conrad Hackett, twitter handle @conradhackett, from Pew research.
Tobacco WorldTobacco companies have a legal right to promote and sell their products in most countries. It’s just unfortunate their promotion and sales efforts are so successful.

What Mammograms Teach Us About Wildfires, Floods, and Tornadoes

colorado-floodIn the wake of the horrific floods that struck Colorado recently, many people have debated whether global warming is to blame. The same goes for wildfires that hit that state this summer and for the massive tornado that struck in Oklahoma this spring. In the wake of that tornado, for instance, Senator Sheldon Whitehouse from Rhode Island claimed that Republican opposition to climate change legislation was at fault, for trying to “protect the market share of polluters.”  Senator Barbara Boxer was confident about the cause of the terrible twister too: “This is climate change” she said.
The same finger pointing occurred after super storm Sandy, with some people even claiming that global warming could make storms like Sandy into the new normal, occurring as often as every other year, and Governor Chris Christie just as adamantly denying that global warming played any role in this storm.
The problem with these debates is familiar to those of us in the medical community who have followed controversies about breast cancer screening—people mistakenly and all too understandably seek out explanations for individual events when science can only tell us about aggregate truths.  For the same reason we cannot tell whether an individual mammogram saved a woman’s life, we cannot determine whether any specific storm is the result of climate change.  Instead, we are left with what we can learn from statistics.
Wondering why we don’t know whether a specific mammography test saved a woman’s life? …(Read more and view comments at Forbes)

Beware of Cancer Metastasizing to Your Wallet

Joanne Reed’s breast cancer was discovered at an early stage, early enough that her doctors would be able to remove the tumor with surgery (either a mastectomy or a lumpectomy) and then, with a touch of chemo, she would face a decent chance of living out her life without a recurrence.
But then Reed’s cancer metastasized to her wallet: “I was working full-time at the time [of my cancer diagnosis] and had pretty good insurance.  But I still had co-pays…anyway, I kept getting bills.”  And unfortunately, she kept getting bills at the same time as her income declined, because the treatments made it difficult for her to continue working: “So our income was cut in half.  And with a husband who is disabled [with schizophrenia]…and I had also had some credit card debt from the past…”
Reed is one of several dozen women who participated in a Duke study (led by an oncologist, Yousuf Zafar) on which I have been collaborating.  The study explores the financial burdens created by cancer diagnoses.  Reed spoke anonymously to our research team (Reed is a pseudonym) and her story is as tragic as it is routine.  Across our interviews, we discovered a wide range of medical and social circumstances impacting patients’ lives.  Some people had early stage cancers, others had more advanced disease; some people had health insurance and others didn’t.  But almost to a person, one fact was consistent across these patients—none of them expected that their cancer treatments would cause as much financial distress as they did.
Even people with decent health insurance may be one serious illness away from economic calamity…(Read more and view comments at Forbes)

Is There a Smart Way to Use the New Oncotype Prostate Cancer Test?

On May 8th, the makers of the oncotype DX Prostate Cancer Test presented results of a large study demonstrating that their test can help men decide whether their prostate cancer carries a low enough risk of progression to forgo surgical or radiation therapy, two treatments that typically eradicate prostate cancers but also cause most men to experience impotence and incontinence.
Lacking such a test, many men have felt compelled to receive these aggressive treatments even though they know that most men in their position—with low grade cancer localized to the prostate—will not experience aggressive, metastatic disease.  Low grade tumors—what are called Gleason 6 and 7 tumors based on how they look under a microscope—do not usually cause fatal illness.
But there are a couple problems with our current staging system, at least in the minds of most patients.  It’s phrases like “don’t usually cause fatal illness”.  Those are troublingly vague words for someone who has just found out he has a cancer diagnosis.  It must mean that some of those tumors turn nasty.
Enter the Oncotype test.  If the test is as good as experts hope it to be (warning: the results have not passed peer review muster yet), if the test better identifies safe tumors that have almost no chance of spreading, then men should be able to avoid those nasty treatments.  And they should also be able to avoid the costs of being monitored every six months with prostate blood tests and biopsies.
But will human psychology interfere with optimal use of the Oncotype test? … (Read more and view comments at Forbes)

Who Wants to Take a Pill to Prevent Breast Cancer?

On April 14, The United States Preventive Services Taskforce concluded that women with an elevated risk of breast cancer – who have never been diagnosed with breast cancer but whose family history and other medical factors increase their odds of developing the disease–should consider taking one of two pills that cut that risk in half. The Taskforce is an independent panel of medical experts who review the medical literature to estimate the pros and cons of preventive interventions. This is the same Taskforce that in recent years raised questions about the benefits of mammograms in 40 to 50-year-old women, and PSA tests for men of all ages, tests that screen respectively for breast and prostate cancer. Despite the popularity of both of these tests, the Taskforce concluded that their harms often outweigh their benefits.
The irony now is that with this report on breast cancer prevention pills, the Taskforce has switched from rejecting something patients believed in to endorsing something most patients will reject.
The seemingly strange way the Taskforce ping-pong’s between popular and unpopular recommendations is inevitable, because these kinds of recommendations must necessarily go beyond the medical facts – it is impossible to decide what preventive measures people need without making value judgments.
To understand the way facts and value judgments get mixed together in these kinds of recommendations, let’s take a closer look at these breast cancer prevention pills… (Read more and view comments at Forbes)

Will the Sequester Cause Oncologists to Lose Money Prescribing Chemotherapy?

In a recent Washington Post article, Sarah Kliff reported that “Cancer clinics across the country have begun turning away thousands of Medicare patients” because of reductions in reimbursement caused by the sequester. Specifically, oncologists will no longer be able to markup the price of chemotherapy by 6% “to cover the cost of storing and administering” the drugs. As health executive Jeff Vacirca put it: “If we treated the patients receive the most expensive drugs, we’d be out of business in six months to a year.”
Is the sequester really going to bankrupt oncologists? And are these oncologists right to stop treating Medicare patients?
There are no easy answers to this question. On one hand, the 6% mark up exerts a disturbing influence on oncologist’s treatment decisions. As I discussed in an earlier post: “This “buy and bill” practice creates an incentive for oncologists to prescribe expensive treatments.” In fact, when a popular chemotherapy drug went generic, oncologists switched to a non-generic competitor, thereby increasing the size of the 6% mark up… (Read more and view comments at Forbes)

Should Doctors Give Medical Advice to Strangers over Email?

Recently I received an email from someone I have never met, who asked me the following:

“Could you refer me to any current study results on Arimidex (Anastrozole)? My oncologist is not helpful. My oncotype dx said I have 9% chance of recurrence and with Arimidex for 5 years that is reduced to 4.5 %. Not sure it is worth it?
I remember being mocked because I wouldn’t take HRT in 1996. He chided me that after my uterus was removed I needed it for my heart. Turns out that was not true. Makes me wonder.
Any current info would be helpful.”

One of the joys of writing for broad audiences is that I get to interact with people outside the worlds of academia and medical practice. And since writing Critical Decisions, I have received an increasing number of emails from people who say the book has helped them through their own medical journeys. On the other hand, that sometimes puts me in the awkward position of trying to figure out how to handle anonymous requests for medical advice… (Read more and view comments at Forbes)

What the World Got Wrong About Lance Armstrong and Oscar Pistorius

Lance Armstrong cheated and bullied. These are not shocking revelations. Oscar Pistorius had a history of altercations with his girlfriend and is now accused of murder. More shocking, by far, but hardly the first athlete to be accused of such wrong doing.
Should we be so thoroughly shocked to find out the Armstrong and Pistorius are deeply flawed? Remember: the same traits that make people successful as elite athletes—obsessive focus, unrelenting ambition—can also make them rotten human beings.
Yet, we suppressed thoughts of Armstrong ‘s jerkiness because he is a cancer survivor. And we didn’t focus on Pistorius’s previous bad behavior because he is a double amputee. And in this manner, we made our big mistake… (Read more and view comments at Forbes)