Tuesday, February 25, 2014

Fighting the War Against Cancer

A little context, please.

In the 2012 presidential campaign Barack Obama torched his opponent for suggesting that the government should stop funding Planned Parenthood.

Obama said:

When Governor Romney says that we should eliminate funding for Planned Parenthood, there are millions of women all across the country who rely on Planned Parenthood for not just contraceptive care. They rely on it for mammograms, for cervical cancer screenings.

Some media outlets quickly pointed out that Planned Parenthood does not perform mammograms. It refers women to outside providers.

Still, the damage was done. As always, Romney failed to respond with sufficient vigor and the meme contributed to the concept that Republicans were trying to compromise women’s health.

A recent study from Canada, however, has shown that yearly mammograms are not necessarily such a good thing.

Cancer surgeon Marty Makary writes in Time:

A recent study found that yearly mammograms do not prolong the lives of low-risk women between the ages of 40 and 59. Following 89,000 women for 25 years in a randomized controlled trial (the gold standard of science), the study is as methodologically impressive as they come. In fact, in research terms, the report has more scientific merit than any medical study of chemotherapy. As hard as it is for our pro-screening culture to believe, the data are clear. We are taxing far too many women not only with needless and sometimes humiliating x-rays, but also with unnecessary follow-up surgery.

It is worth noting that many of the extra tests and procedures are anything but benign. And, we emphasize that the Canadian study recommended that women do regular self-examinations.

Makary also underscored another important point. As a nation we screen too much for disease:

New research is finding that some health screening efforts have gone too far.

The annual mammogram is not the only vintage medical recommendation under scrutiny recently. Another large study found that among low-risk adults, a daily aspirin — a recommendation hammered into me in medical school — kills as many people from bleeding as it saves from cardiac death. Doctors are also re-evaluating calls for regular prostate-specific antigen (PSA) tests and surgical colposcopies after “borderline” Pap smears because of the risks of chasing false positives and indolent disease.

In his article, Makary was re-evaluating his own approach to cancer. Being a cancer surgeon, and having seen many people from the disease, he wants to do everything possible to prevent the disease, or better, to stop it before it becomes incurable.

Yet, our culture has cast him, like other physicians, as an armed combatant in the war against cancer:

As a surgeon, I’m trained to crush cancer. For many years, every tumor I palpated and family I counseled drove me to hunt for cancer with vengeance, using every tool modern medicine has to offer. 

Who could possibly argue with that?

And yet, in their zeal to do battle with the great killer, physicians mistook good intentions for good results. Imagining that they were doing God’s work they failed to evaluate the outcomes of the tests objectively.

Makary explains how he discovered this:

The patient’s story began with a full-body CAT scan, a screening test used to detect tumors, which revealed a cyst on his pancreas. Some 3 percent of humans have these cysts and they are rarely problematic. Based on his cyst’s size and features, there was no clear answer as to what to do about it, but he was given options.

The patient tossed and turned every night, agonizing over stories of pancreas cancer tragedies, consumed by the dilemma of whether to risk surgery to remove the cyst or leave it alone. The conundrum strained his marriage and distracted him from his work.

Months before I met him, the patient underwent the surgery, which revealed that the cyst was of no threat to his health. The operation was supposed to cost $25,000 and eight weeks out of work. But the toll was much greater, including a debilitating surgical complication.

I thought: this is why he shouldn’t have had a CAT scan in the first place. Screening made him sick.

In truth, information about the risks of overtesting and performing unnecessary procedures has been around for a while now. I have reported on it here.

It is good to see surgeons question what have become standard prophylactic procedures and that they stop touting the virtues of screenings that cost the nation a massive amount of money, provide little benefit and occasionally cause harm.


Lastango said...

With regard to excessive breast cancer screening, part of the problem is that it long ago (a) became political, and (b) developed a constituency. The Left conflated women's rights and women's bodies into a gauzy spirituality in which it became impossible to oppose throwing money at breast cancer without being "against women". A screening industry - agencies, pseudo-charities, and carpetbagging social justice groups - suckled at the river of public money flowing into the issue. Hangers on, like politicians, corporations, and image-conscious sports leagues joined in as a way of doing PR for themselves and marketing to women.

With regard to the legitimate push against other forms of excessive screening, there is something dangerous taking form on the horizon.

(Let me interject that I recognize the downsides of random screening and overreaction. It's been a problem since scans were first introduced. Investigating every dark mass and anatomical anomaly is not only stressful and dangerous, it is also an ethical hazard for revenue-hungry practitioners.)

The root of risk in the campaign against over-testing is that politicians have over-promised medical care, positioned it as a human right, refused to manage costs, and pander by making it "free" to as many people as possible.

The result is that health care systems are over-strained and unaffordable. Politicians have discovered a political solution to this: cleverly deny actual care, while making the health care system "available" to all. The Brits do this trick well.

There may be two main ways of perpetrating this fraud. The first is waiting lists. Yes, health care is free and theoretically available to all -- but no, you can't get any in a timely manner. The fact that people die while waiting, or that their conditions become worse in a way that hastens death or renders treatment ineffective, is of course deplored as a horrible outcome of waiting lists. But to a calculating politician, avoiding costs of care by having people die is a feature, not a bug. That's why death panels are becoming a reality under Obamacare, and why there is new reporting by the Left's sockpuppet media about subtle ways to shoehorn more people into the legitimate category of "palliative care" so they don't need to be treated. The progressivists will not allow Obamacare to wreck on a medical cost iceberg, so they need to ensure that as few people as possible get treated.

This is where testing comes in. Sophisticated medical testing is the gateway to complex treatment. If the testing doesn't happen, the treatment doesn't happen. The Lefties have figured this out. By denying access to testing, they avoid having to deliver care at what would be ruinous cost, and the fiction of national health care can be maintained.

So, let's beware when a chorus of voices appears discovering the perils of "unnecessary" testing. Their campaign has, for them, the beauty of providing the same outcome as death panels without the political peril of having actual panels deciding on individual cases and without the high-visibility deaths produced by waiting lists. Instead, the progressives will ration care by limiting access to testing. They know the public will never make the connection, just as the public has never figured out that an axis of Wall Street, the Fed, Washington agencies, and the wealthy elite are working together to loot the nation. There are too many links in the causal chain for the public to catch on -- especially when politicians and their getaway drivers in the media have hijacked legitimate concern about over-testing to help manage down the perceived need for medical testing that could lead to costly treatment a national health care system will never be able to actually deliver.

People who need testing and treatment will worsen and die, just as they do now in the UK due to the waiting lists which have become part of how the free-to-all public health system there deliberately rations actual care.

Lastango said...

I see Kathy Shaidle has a piece up about the breast exam industry. "Big Boob" she dubs that racket. Heh.