Pharmacological nonchalance

Dr. Susan Love says that while annual doctor visits may feel reassuring, there is no evidence that they yield better health outcomes.

''There is no data that yearly physicals do anything,'' said Dr. Love, a breast cancer researcher and prominent women's health advocate in Santa Monica, Calif.

The benefit of screening is like a sale, only you don’t save money — you “save” on your chance of dying. Whether you save a lot or a little depends on the “regular price”: your chance of dying without screening.

For most of us, the chance of dying of cancer in a given 10-year period is small: less than 1 percent. So regular screening with a proven test may bring a 20 percent reduction in a 1 percent risk over a decade. Put another way, two deaths would be prevented for every 1,000 people screened during that period.

And what of the other 998 whose fate was not changed by screening? Some of them will have been harmed.

The most familiar harm is a false alarm: The screening test is abnormal, but in the end there is no cancer. False alarms matter because the follow-up tests needed to rule out cancer can be painful, dangerous and scary.

But overdiagnosis — the detection of cancers never destined to cause problems — is arguably the most important harm of screening. Some cancers grow so slowly that they would never cause symptoms or death. When screening finds these cancers, it turns people into patients unnecessarily.

Since there is no reliable way to know whether a screening-detected cancer represents overdiagnosis, most people seek treatment. People on the receiving end of overdiagnosis can only be harmed — sometimes seriously — by unnecessary surgery, radiation and chemotherapy. While it’s hard to precisely estimate the amount of overdiagnosis that occurs, most experts agree that it’s an inevitable consequence of screening.

The bottom line is that while screening may help some people avoid a cancer death, it will harm many others. We struggle personally, and as doctors, with these trade-offs. We all want to avoid dying of cancer, but no one wants to become a cancer patient unnecessarily.

Q.
But in reading the book, you don’t just blame doctors for being greedy. You blame patients for being gluttonous. Can you explain?

A.
Another patient of mine had early colon cancer. Three doctors had told her she should not get chemotherapy. She decided she wanted it, and she went doctor-shopping until she found a doctor who would give it to her. Her insurance had no way to object to her getting this inappropriate chemotherapy because privacy laws prevent disclosing the stage of the disease to the insurance company. She was referred to me by a relative who was concerned about what she was doing. She readily admitted that she had three different medical opinions that said she should not get chemotherapy, but she wanted chemotherapy. So a doctor made $10,000 off that six months of chemotherapy, and she got an increased risk of leukemia for the rest of her life, not to mention losing her hair and everything else, with no scientific evidence that the treatment reduced her risk of the colon cancer coming back.

I blame patients, I blame doctors, I blame hospitals, I blame drug companies, I blame insurance companies. Our health care system is messed up because the system is designed to fail, and everybody is responsible for health care failing as it is now.

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.

“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative. “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”

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The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

[....]

“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”

“I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”

The docs who get talked into prescribing this and that - it's so far out of my ken with any doc I went to or worked with, I'm sort of flabbergasted that it's happening.