Chicken or the Egg –”Which Came First” Argument Invades Treatment & Reimbursement Policy?

You really do have to wonder. Amidst all the talk –for decades– about the need to get regular check-ups, screenings, etc., to catch deadly cancers before they spread, it’s a bit puzzling that one fresh study after another is now concluding otherwise. Let’s see. We are supposedly living in an era that will be marked by the renaissance of primary care, yet no major medical group recommends routine PSA blood tests to check men for prostate cancer and now a government panel is saying that they do more harm than good. Huh? Peter Griffin (Family Guy) will be pleased, but I’m not sure about anyone else.

And now mammograms!

A new study indicates that up to 33% of breast cancers (~60,000 cases each year) don’t need treatment. In the most comprehensive study yet published, evidence is presented that mammograms aren’t all they’re cracked up to be.  “We’re coming to learn that some cancers — many cancers, depending on the organ — weren’t destined to cause death,” said Dr. Barnett Kramer, a National Cancer Institute screening expert. Despite the fact that breast cancer is the leading cause of cancer deaths in women worldwide, aggressive screening is already frowned upon most everywhere other than the U.S., so should we be surprised?

Researchers used federal surveys on mammography and cancer registry statistics from 1976 through 2008. Mammograms more than doubled the number of early-stage cancers detected — from 112 to 234 cases per 100,000 women. But late-stage cancers dropped just 8 percent, from 102 to 94 cases per 100,000 women. The imbalance suggests a lot of over-diagnosis from mammograms, which now account for 60 percent of cases that are found. “If screening were working, there should be one less patient diagnosed with late-stage cancer for every additional patient whose cancer was found at an earlier stage,” explained one of the researchers. “Instead, we’re diagnosing a lot of something else — not cancer– in that early stage and the worst cancer is still going on, just like it always was.” Researchers also looked at death rates for breast cancer, which declined 28 percent during that time in women 40 and older — the group targeted for screening. Mortality dropped even more — 41 percent — in women under 40, who presumably were not getting mammograms. “We are left to conclude, as others have, that the good news in breast cancer — decreasing mortality — must largely be the result of improved treatment, not screening,” the authors write.

Dr. Len Lichtenfeld, the cancer society’s deputy chief medical officer, said the study should not be taken as “a referendum on mammography,” and noted that other high-quality studies have affirmed its value. Still, he said over-diagnosis is a problem, and it’s not possible to tell an individual woman whether her cancer needs treated. “Our technology has brought us to the place where we can find a lot of cancer. Our science has to bring us to the point where we can define what treatment people really need,” he said.

Well, it’s good to know that such fresh wisdom can also be so timely –that it can continue to surface right smack in the middle of a complete overhaul of the US healthcare system. I’m sure it has nothing to do with the emotional debate around rationing or the need for providers to now focus on quality of outcomes versus quantity of procedures. It’s like being the guy in the room who can enumerate all the wonderfully altruistic reasons for US involvement in the Middle East, but who at the same time refuses to acknowledge that oil might, in fact, have something to do with it. Which came first, a new reimbursement policy that simply cannot digest the current appetite for regular screening or a new medical study promoting results that conveniently promote that the current rate is not necessary –if not harmful (for good measure).

This latest study was completed in 2008, but we’re hearing about it now. And I can get my genome in 3 minutes?  While I’m sure my cynicism here is easily debunked, I just can’t help but point out how alarming the timing for this story and other similar ones continues to be –at least to me. Fortunately, we’ve moved away from an era where virtually everything was said to have caused cancer. My favorite: “The FDA has concluded that saliva causes cancer. But not to worry, the study found that it only happens in cases where the saliva is consumed in small quantities over a long period of time…”

Times have changed.  Advances in research and the practice of medicine used to shape policy –and politics. And now politics, despite every effort we make to the contrary, is going to impact the research and practice of medicine. Yes, there was always a little overlap, but in fact, times have changed for us chickens and our offspring.

—Tom Finn


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