The Dilemma of Modern Medical Care: More is Not Always Better
Here’s the third in our occasional series of newsletters on getting better medical care for yourself and your family. Not coincidentally, we’re sending it on that greatest of days, St. Patrick’s Day. I wish I could say he was the patron of good health, but at least he’s the patron of good cheer!
Today, we’re discussing tragedy and how to prevent it. The two biggest killers in America are heart disease and cancer. Diet and exercise are two proven ways to ward off both. But what about medical interventions? There, the news is not so great. In the heart, balloons and stents are vastly overused and fail to deliver benefit for most people. In cancer, two of the most common screening tests — mammograms and the PSA blood test — also don’t do a lot of good for most people.
This is not a blanket condemnation. One lesson of modern medicine, seen over and over, is that a test or treatment starts out as being pretty good for a narrow group of patients, but then gets expanded to more and more people who don’t get the help and just get exposed to the downside: risk of injury or even death.
A lot of us think that the only people who should care about excessive tests and treatments in medicine are the insurance bean counters. I’m not one of those. I care about unnecessary treatments because I’ve seen too many clients get hurt by undergoing something that they really didn’t need in the first place.
You will see three articles in this newsletter expanding on these thoughts: one about heart attack treatments, one about removal of healthy breasts in scared cancer survivors, and a final one about screening with PSA testing and mammograms.
By the way, don’t get the idea I’m opposed to all medical testing. In the cancer field, colonoscopies and Pap smears are proven to save many lives. That’s just one example. But I’m a believer in hard numbers, and the numbers don’t pan out well for many other tests and treatments, at least in a lot of patients. To be a smart consumer, you have to learn enough to know if you’re in the group that can be helped, or the group where it’s more wishful thinking than hard evidence.
When Low-Tech Beats High-Tech: Lessons from Heart Attack
When a 44-year-old male friend dropped dead the other day from a massive heart attack — no prior symptoms, no warning of any kind — I wondered if modern medicine could have done anything to prevent the tragedy. The answer I learned is that low-tech still beats high-tech hands down in preventing America’s No. 1 killer.
Low-tech means getting regular exercise, eating right and paying attention to cholesterol, blood pressure and the other risk factors for heart disease, and it also means moving fast to get to a medical facility with any symptoms whatsoever that might be signaling heart attack. Those are the proven ways to lengthen your life span and avoid early death.
But my friend didn’t have any symptoms or risk factors. What could he have done? That’s where high tech comes in, but the answers are not encouraging. The available treatments are expensive and not very effective for people without symptoms.
He could have had the gold-standard test for narrowed arteries in the heart: an angiogram. That’s an X-ray movie of the arteries that involves putting a tube into the groin, threading it up to the surface of the heart, and squirting dye through the tube to outline the inside of the blood vessels as high-speed multiple X-rays are taken. I’ve watched these movies for some of my medical malpractice lawsuits, and they are eerily fascinating: the dye looks like smoke as it pushes out of the tube and mingles with the blood in the arteries, which suddenly light up as if a switch has been turned on, with the heart quivering all the while behind the arteries.
The problem is that most of the time, angiograms on people without chest pain symptoms show nothing. Even when there are some symptoms, the angiogram is just as likely to turn up clean as a whistle, or with only minor narrowing, as it is to show serious disease.
A new study in the New England Journal of Medicine of 400,000 patients found that the odds of finding operation-worthy heart disease in patients getting a first-time angiogram without any known heart disease was only four in ten — which means that the $2,500 procedure was wasted on six of every ten patients.
Now, you might think that the angiogram can still be worthwhile if it shows some blockages that can be cleaned out. But that’s true ONLY IF those blockages are causing symptoms. The usual technique to unblock arteries — with a balloon and a wire scaffolding (stent) to hold open the artery — has been shown to work to relieve symptoms of chest pain, but it does NOT extend life in symptom-free patients. In those patients, it’s thought that the heart has already learned how to deal with the blockage by shifting blood from another supply.
Here is a very good article from Harvard Medical School on who should get the balloon treatment — called angioplasty — and who shouldn’t.
The bottom line: Angioplasty can save your life during a heart attack if it can be done fast enough to open the artery before permanent damage is caused to the heart muscle. But for symptom-free patients — even with proven blockages — angioplasty is worthless and exposes patients to the risk of dying from a complication of having wires and tubes poked into your heart. And for patients with non-debilitating chest pain, angioplasty doesn’t work any better than taking drugs and making lifestyle changes.
People who get chest pain and learn they have heart disease should think of the pain as a gift from on high: It’s given them a chance for a new lease on life. But for people like my friend whose first symptom is a fatal heart attack, there’s not much that medicine can do. We’re all fated to die at some time, and we haven’t learned how to defeat fate. We can and should pay close heed to getting plenty of exercise, eating right and doing other things to lower our risk. But the risk will always be there.
Removal of a Healthy Breast: Peace of Mind or Unnecessary Treatment?
This is a case study of how scary cancer is in the 21st century, after we’ve spent billions of dollars searching for a cure.
More and more women with cancer in one breast are now opting to have the other healthy breast removed as well, even though the statistics show survival odds don’t improve by having both breasts removed and most patients end up with chests that are numb to sensation.
Peace of mind is cited by many of these cancer patients for their decision.
A new report by Tara Parker-Pope in the New York Times details this trend, and the Times’ “Well” Blog has a number of interesting and moving comments from women and cancer experts.
As many as three in ten breast cancer surgeries in large urban cancer centers are for preventive removal of the healthy breast, the Times reported.
But what is prevented, exactly?
The only women who get a very slight survival bump from having their healthy breast removed are patients under age 50 who have estrogen-negative cancers that don’t respond to drugs like Tamoxifen. For everyone else, there is no real advantage in having the second breast removed. When the second breast gets cancer, as happens sometimes, that is not “spread” from the original cancer but is a new, unrelated cancer.
The real risk that women face from the original cancer is that it has already spread beyond the breast, but removal of the second breast doesn’t help that risk.
The most striking evidence of how afraid of cancer women are is with DCIS: ductal carcinoma in situ, which is not even considered true cancer by many experts because it either disappears or never progresses in two-thirds of women. Yet still many women with DCIS are electing to have not just the one breast removed, but both.
Ultimately, this is an intensely personal decision. But it helps to get the true facts first.
Cancer Screening: Controversies about Mammograms in Women and PSA Testing in Men
Breast Cancer Screening
I’ve written several reports on breast cancer screening in my patient safety blog. The most recent, which I called “The Quiet Truth About Breast Cancer Screening,” was taken from a discussion by the National Breast Cancer Coalition. Read more here. Here’s an excerpt from another piece I wrote on the subject last summer:Imagine if every 50-year-old woman thinking about whether to have a mammogram received the following “balance sheet” showing the “credits” and “debits” as understood by the latest research:
For every 1,000 women who have a yearly mammogram over the next ten years:
1 woman will avoid dying from breast cancer
2-10 women will be overdiagnosed and treated needlessly
10-15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis
100-500 women will have at least one “false alarm” (about half of these women will undergo a biopsy)
These numbers appear in an editorial in the British Medical Journal in July 2009, written by Dartmouth researcher H. Gilbert Welch, M.D., in response to news that the British National Health Service had scrapped a proposed pamphlet that would have described the benefits of mammograms, but failed to talk about their downside.
The key comparison in the above balance sheet is the ratio of one woman’s life saved for every two to ten lives harmed by overdiagnosis. The one-to-two ratio comes from a study three years ago by Zackrisson and colleagues. The one-to-ten ratio is from a more recent study by Gotzsche. The tipping point for women in deciding whether to undergo annual mammogram screening is probably somewhere on this sliding scale. The test might not feel worthwhile if ten women are hurt for every one helped, but might seem worth it if only two were hurt for every one helped.
As the author writes:
Mammography is one of medicine’s “close calls”-a delicate balance between benefits and harms-where different people in the same situation might reasonably make different choices. Mammography undoubtedly helps some women but hurts others. No right answer exists, instead it is a personal choice.
To inform that choice, women need a simple tabular display of benefit and harms-a balance sheet of credits and debits.
Unfortunately, medicine hasn’t yet pinned down the precise numbers on the balance sheet. For now, women need to be informed that there are varying estimates, and they need to make their own decisions.
Readers should note that this discussion applies only to cancer screening in low-risk women who have no noticeable lumps; women who can feel a lump in their breast are in a different risk category and need to see a doctor promptly.
PSA Testing for Prostate Cancer
The man who discovered the PSA test for prostate cancer now says the test is so overused it has become a public health disaster with an annual price tag of $3 billion in wasted testing.
Dr. Richard Ablin writes an op-ed in the New York Times calling for the test to be abandoned for routine cancer screening for men over age 50. At most the test is useful in men with a family history of prostate cancer and also useful to detect cancer coming back in men who have already has their prostates removed for cancer.
Here’s what I wrote about PSA testing after two huge studies came out a year ago. One study that followed 77,000 American men for a decade found zero benefit in lowered death rates, while the other study, which followed 182,000 Europeans for nine years, found that only seven lives were saved for every 10,000 men screened with the blood test.
And for every one of those saved lives, forty-eight men were told they had cancer and underwent unnecessary treatment. That treatment can cause impotence or incontinence if it involves surgery, or problems with bowel elimination if it involves radiation.
The problem is not so much the test but the disease. Prostate cancer is usually very slow to grow, and in the cases where it is aggressive, it may already be too late to save the patient when it is discovered.
Here’s to a healthy 2010!
Patrick Malone & Associates