August 5, 2013 | 10
I’ve complained in previous columns about excessive medical testing, which leads to unnecessary treatment and drives up health care costs. Overtesting helps explain why health-care costs for Americans are much higher than in any other nation, whereas our health ranking is low, roughly equivalent to that of Cubans.
The medical establishment is gradually acknowledging these hard facts, as indicated by a recent article in the Journal of the American Medical Association: “Overdiagnosis and Overtreatment in Cancer: An Opportunity for Improvement.” The article was written by a working group formed by the American Cancer Institute last year “to develop a strategy to improve the current approach to cancer screening and prevention.”
The three authors state: “Over the past 30 years, awareness and screening have led to an emphasis on early diagnosis of cancer. Although the goals of these efforts were to reduce the rate of late-stage disease and decrease cancer mortality, secular trends and clinical trials suggest that these goals have not been met; national data demonstrate significant increases in early-stage disease, without a proportional decline in later-stage disease.”
In other words, increased screening has led to increased diagnosis of cancer but has not significantly decreased mortality. The problem with screening, the authors note, is that “cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime.”
That is, screening often detects growths that represent no significant threat and yet are nonetheless often treated with surgery, chemotherapy and radiation, all of which degrade health. The authors state: “Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with cancer screening.” [Italics in original.]
“Policies that prevent or reduce the chance of overdiagnosis and avoid overtreatment are needed,” the authors assert, “while maintaining those gains by which early detection is a major contributor to decreasing mortality and locally advanced disease.”
One policy change that the authors recommend would be to avoid using the term “cancer” to describe tumors or other abnormalities that are not life-threatening. When patients hear the word “cancer,” they often demand further tests and treatment, even when medically unjustified, and physicians are too often eager to comply.
The JAMA article, if anything, downplays the problems with cancer testing. For example, the authors state that “colon and cervical cancer are examples of effective screening programs in which early detection and removal of precancerous lesions have reduced incidence as well as late-stage disease.” As I stated in a column last year, “Why I Won’t Get a Colonoscopy,” the value of colonoscopies has not been clearly demonstrated.
In that same column, I quoted Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice Welch, writing in The New York Times that screening healthy people leads to “needless appointments, needless tests, needless drugs and needless operations (not to mention all the accompanying needless insurance forms).”
Welch, author of the excellent book Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press, 2011), added, “This process doesn’t promote health; it promotes disease. People suffer from more anxiety about their health, from drug side effects, from complications of surgery. A few die. And remember: these people felt fine when they entered the health care system.”
Welch and a colleague estimate in The New England Journal Of Medicine that 70,000 American women were overdiagnosed with breast cancer in 2008. As I have reported previously, men who take a prostate-specific antigen test and receive a cancer diagnosis have been estimated to be 47 times more likely to get unnecessary, harmful treatments—biopsies, surgery, radiation, chemotherapy—than they are to have their lives extended.
The Affordable Health Care Act represented a reasonable step toward reforming over-priced, under-performing American medicine. But true reform will require ending the epidemic of overtesting and over treatment, which is bankrupting us without improving our health.
Photo by Rhoda Baer, National Cancer Institute, courtesy Wikimedia Commons.