Many of the primary care-relevant recommendations in the Choosing Wisely campaign advise physicians to think twice before reflexively ordering diagnostic imaging tests in certain clinical situations. Inappropriate imaging increases radiation exposure, leads to overdiagnosis and detection of incidentalomas, and increases costs for patients and health systems. In addition, as Drs. Brian Crownover and Jennifer Bepko observe in the April 1st issue of American Family Physician, increasing radiation exposure is likely to lead to higher rates of cancer diagnoses and deaths:
In 2006, 380 million radiologic procedures (including 67 million computed tomography [CT] scans) and 18 million nuclear medicine procedures were performed in the United States. To highlight the disproportionate use, U.S. patients received approximately one-half of all nuclear medicine procedures worldwide while making up only 4.6 percent of the global population. The volume represents a sixfold increase (from 0.5 to 3.0 mSv [millisieverts]) in annual per capita radiation exposure from 1980 to 2006. ... Increasing recognition of future cancer risk from radiation exposure was illustrated in a 2009 study showing that 2 percent of all future cancer cases will likely come from previous CT exposure, resulting in approximately 15,000 deaths annually.
This article on the appropriate and safe use of diagnostic imaging goes on to review consensus indications for imaging in the central nervous system, chest, abdomen, and lumbar spine based on American College of Radiology appropriateness criteria. It includes a helpful Table on the average effective radiation doses of medical imaging procedures that clinicians may use to weigh the harm versus the potential benefit of a particular diagnostic imaging test. In general, the authors recommend discouraging patients from undergoing whole body scanning, which is associated with numerous health risks and no proven benefits.
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This post was first published on the AFP Community Blog.
Monday, 29 April 2013
Thursday, 25 April 2013
Pink ribbons don't cure breast cancer
"I used to believe that a mammogram saved my life," begins breast cancer survivor Peggy Orenstein in a revelatory New York Times Magazine story that every woman (and man) should read before making personal decisions about screening for cancer. Although the ubiquitous spectacle of pink ribbons for "cancer awareness" has certainly raised breast cancer's profile as disease, Orenstein raises serious concerns about whether these campaigns have been good for patients:
Before the pink ribbon, awareness as an end in itself was not the default goal for health-related causes. Now you’d be hard-pressed to find a major illness without a logo, a wearable ornament and a roster of consumer-product tie-ins. Heart disease has its red dress, testicular cancer its yellow bracelet. During “Movember” — a portmanteau of “mustache” and “November” — men are urged to grow their facial hair to “spark conversation and raise awareness” of prostate cancer (another illness for which early detection has led to large-scale overtreatment) and testicular cancer.
Before the pink ribbon, awareness as an end in itself was not the default goal for health-related causes. Now you’d be hard-pressed to find a major illness without a logo, a wearable ornament and a roster of consumer-product tie-ins. Heart disease has its red dress, testicular cancer its yellow bracelet. During “Movember” — a portmanteau of “mustache” and “November” — men are urged to grow their facial hair to “spark conversation and raise awareness” of prostate cancer (another illness for which early detection has led to large-scale overtreatment) and testicular cancer.
“These campaigns all have a similar superficiality in terms of the response they require from the public,” said Samantha King, associate professor of kinesiology and health at Queen’s University in Ontario and author of "Pink Ribbons, Inc.” “They’re divorced from any critique of health care policy or the politics of funding biomedical research. They reinforce a single-issue competitive model of fund-raising. And they whitewash illness: we’re made ‘aware’ of a disease yet totally removed from the challenging and often devastating realities of its sufferers.”
As I've blogged before, there are no easy victories in cancer screening and prevention. Physicians, researchers, politicians, and health advocates who exaggerate the benefits and minimize the harms of early detection of cancer with mammograms and other tests ultimately do patients a disservice. Orenstein makes this case on the personal and public health levels:
The idea that there could be one solution to breast cancer — screening, early detection, some universal cure — is certainly appealing. All of us — those who fear the disease, those who live with it, our friends and families, the corporations who swathe themselves in pink — wish it were true. Wearing a bracelet, sporting a ribbon, running a race or buying a pink blender expresses our hopes, and that feels good, even virtuous. But making a difference is more complicated than that.
It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk.
As I've blogged before, there are no easy victories in cancer screening and prevention. Physicians, researchers, politicians, and health advocates who exaggerate the benefits and minimize the harms of early detection of cancer with mammograms and other tests ultimately do patients a disservice. Orenstein makes this case on the personal and public health levels:
The idea that there could be one solution to breast cancer — screening, early detection, some universal cure — is certainly appealing. All of us — those who fear the disease, those who live with it, our friends and families, the corporations who swathe themselves in pink — wish it were true. Wearing a bracelet, sporting a ribbon, running a race or buying a pink blender expresses our hopes, and that feels good, even virtuous. But making a difference is more complicated than that.
It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk.
Read the full text of "Our Feel-Good War on Breast Cancer" here.
Thursday, 18 April 2013
The worst kind of guideline
Before critiquing the American College of Physicians' recent guidance statement on screening for prostate cancer, I will begin by saying that I generally hold the ACP's clinical guideline development process in high regard. They often base their guidelines on comprehensive and methodologically sound reviews of the evidence produced by Evidence-Based Practice Centers. In some cases, when several good-quality guidelines are already available, the ACP chooses not to reinvent the wheel and instead critically appraises the existing guidelines, as it did this time. The authors of the guidance statement are respected experts in evidence-based medicine, including Informed Medical Decisions Foundation president Michael Barry and current U.S. Preventive Services Task Force member Douglas Owens.
That being said, I won't mince words. On screening for prostate cancer, the ACP's guideline committee laid an egg.
The ACP's appraisal of the evidence on screening with the prostate-specific antigen (PSA) test was remarkably similar to the U.S. Preventive Services Task Force's assessment: harms of the test outweigh benefits. The ACP recommended that clinicians inform men between the age of 50 and 69 years of the rationale behind this conclusion, and provide a helpful, if overly extensive, list of "talking points with patients" which seem designed to discourage men from getting the test. All well and good. But what about men who absorb all of this information and still want to get screened? Well, the ACP says, go ahead and give them the test.
In what other area of medicine are physicians explicitly instructed to provide interventions that are judged do more harm than good because patients request them? To use a counter example, the vast majority of upper respiratory infections are due to viruses. Nonetheless, many of my patients request antibiotics. Antibiotics may benefit individual patients with upper respiratory infections in exceedingly rare cases, but on a population level clearly do more harm than good - leading, for example, to diarrhea, allergic reactions, and increasing bacterial resistance. But what if, after I finish patiently explaining all of these facts, the patient still "expresses a clear preference" for an ineffective and potentially harmful antibiotic prescription? Should I then go ahead and prescribe it? If I applied the ACP's approach to PSA screening, the answer would be yes.
In a thoughtful commentary published this week in JAMA Internal Medicine, L.A. County Department of Health Services Director Mitchell Katz asks the obvious question:
First, when as a profession did we decide that we had an ethical obligation to offer interventions that cause more harm than good? When we offer an intervention that is on the whole detrimental, are we not sending our patients a mixed message? Presumably there are any number of interventions that cause more harm than good. Should we be offering our patients a menu of ineffective interventions on the idea that they are better able than we are to determine effectiveness?
The ACP's guidance statement on PSA screening is even more perplexing when viewed in the context of the organization's participation in laudable efforts to prevent unnecessary or harmful medical care, including the High Value Care Initiative and the Choosing Wisely campaign. The success of these campaigns will depend on the ability of individual physicians and health systems to reduce waste and refocus resources on care that is most likely to benefit patients. Dr. Katz goes on to recount a conversation with a colleague about the hypothetical elimination of PSA screening tests in his health system:
If I cannot eliminate PSA testing, for which there is a USPSTF conclusion that the test cannot be recommended for men of any age, what is the likelihood that I could eliminate any low-value test, given that most things are not so well studied with such clear expert advice? ... Much of why the US health care system is so expensive for the benefits we gain is because we do not treat it like a system. If a new test or treatment is approved, we increase premiums to pay for it. Although we are slowly incorporating cost-effectiveness data into medical choices, especially when choosing among drugs used for the same indication or among diagnostic algorithms for evaluating a particular symptom, there is little dialogue about how to divert money from low-value care to higher-value care.
Good guideline recommendations must be concordant with the evidence upon which they are based. I may disagree vehemently with the American Urological Association about the value of PSA screening, but to their credit, their 2009 guideline at least interpreted the evidence as supporting a net benefit from the test. But to conclude, as the ACP did, that the PSA test causes more harm than good to patients, but allow physicians to provide it anyway, is nonsense. It is a huge step backward from high-value care. It is Choosing Unwisely. It is, in my opinion, the worst kind of guideline.
That being said, I won't mince words. On screening for prostate cancer, the ACP's guideline committee laid an egg.
The ACP's appraisal of the evidence on screening with the prostate-specific antigen (PSA) test was remarkably similar to the U.S. Preventive Services Task Force's assessment: harms of the test outweigh benefits. The ACP recommended that clinicians inform men between the age of 50 and 69 years of the rationale behind this conclusion, and provide a helpful, if overly extensive, list of "talking points with patients" which seem designed to discourage men from getting the test. All well and good. But what about men who absorb all of this information and still want to get screened? Well, the ACP says, go ahead and give them the test.
In what other area of medicine are physicians explicitly instructed to provide interventions that are judged do more harm than good because patients request them? To use a counter example, the vast majority of upper respiratory infections are due to viruses. Nonetheless, many of my patients request antibiotics. Antibiotics may benefit individual patients with upper respiratory infections in exceedingly rare cases, but on a population level clearly do more harm than good - leading, for example, to diarrhea, allergic reactions, and increasing bacterial resistance. But what if, after I finish patiently explaining all of these facts, the patient still "expresses a clear preference" for an ineffective and potentially harmful antibiotic prescription? Should I then go ahead and prescribe it? If I applied the ACP's approach to PSA screening, the answer would be yes.
In a thoughtful commentary published this week in JAMA Internal Medicine, L.A. County Department of Health Services Director Mitchell Katz asks the obvious question:
First, when as a profession did we decide that we had an ethical obligation to offer interventions that cause more harm than good? When we offer an intervention that is on the whole detrimental, are we not sending our patients a mixed message? Presumably there are any number of interventions that cause more harm than good. Should we be offering our patients a menu of ineffective interventions on the idea that they are better able than we are to determine effectiveness?
If I cannot eliminate PSA testing, for which there is a USPSTF conclusion that the test cannot be recommended for men of any age, what is the likelihood that I could eliminate any low-value test, given that most things are not so well studied with such clear expert advice? ... Much of why the US health care system is so expensive for the benefits we gain is because we do not treat it like a system. If a new test or treatment is approved, we increase premiums to pay for it. Although we are slowly incorporating cost-effectiveness data into medical choices, especially when choosing among drugs used for the same indication or among diagnostic algorithms for evaluating a particular symptom, there is little dialogue about how to divert money from low-value care to higher-value care.
Good guideline recommendations must be concordant with the evidence upon which they are based. I may disagree vehemently with the American Urological Association about the value of PSA screening, but to their credit, their 2009 guideline at least interpreted the evidence as supporting a net benefit from the test. But to conclude, as the ACP did, that the PSA test causes more harm than good to patients, but allow physicians to provide it anyway, is nonsense. It is a huge step backward from high-value care. It is Choosing Unwisely. It is, in my opinion, the worst kind of guideline.
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