Overdiagnosis or overtreatment? Move to lung cancer screening fuels debate

A report from HLM on Siemens-sponsored, Atlantic-hosted event on “The Diagnostic Debate.”

Gregory Sorensen, the CEO of Siemens Healthcare North America opened the session by challenging the notion that screening drives overdiagnosis.

“We’re not over diagnosing,” he said. “We’re over treating.”

Sorensen used as an example, mammography. When doctors find a “low-grade” tumor like DCIS (ductal carcinoma in situ), they may resort to a lumpectomy or chemotherapy despite questions about the efficacy of those treatments, he explained.

“This in turn leads us to question the value the mammography, because it leads to overtreatment. It is not the mammogram that’s the problem,” Sorensen asserted. “It’s the [healthcare] system’s lack of discipline.”

Atlantic’s event site. 



Supported by evidence? Mobile health screening gets scrutinized

My latest for HealthLeaders Media looks at Public Citizen charges that a health screening program overstates the promise of its services. Public Citizen takes issue with company claims that cardiac screening saves lives. After issuing am initial statement criticizing Public Citizen as proponent of “government-run health care”, HealthFair now says it wants to work with regulators to ensure the accuracy of its advertising.

The debate over screening for heart disease and other conditions is playing out in a consumer group’s campaign to get hospitals to cut ties with the mobile screening company HealthFair Health Screening.

Last week, Public Citizen expanded its campaign by asking the Federal Trade Commission to investigate whether HealthFair’s promotional materials amount to deceptive advertising.A handful of hospitals have discontinued their relationships with Florida-based HealthFair after Public Citizen’s Health Research Group (HRG) accused the company of “fear-mongering.” In June, Public Citizen contacted HealthFair’s hospital clients and The Joint Commission to complain that company overstates the health benefits of its screening programs.      

Asking advertisers, journalists and politicians to back up claims #evidence #askforevidence

ssA class at Emerson is working to bring the UK’s “Ask for Evidence” program to the US. The program was highlighted last night at Cambridge Science Festival. (TR was on one of the panels)

The premise behind this project is simple: if politicians, companies, or commentators want us to vote for them, buy their products, or believe their claims, then we should take an active role as responsible citizens and consumers in asking for relevant evidence. This campaign seeks to involve the public, YOU, in your own defense against deceit, by encouraging you to question and investigate marketing, media, or policy assertions that you read or hear. At Emerson College, this project is being incorporated into various Marketing and Communication Sciences and Disorders courses in order to engage students in asking for evidence and to collect data on consumer awareness.

Check it out. 



BHN Reports: Gawande on reform — “All health care is local.”

The notion that “all health care is local” may sound odd coming from someone who has been deeply involved in health reform at the national level.

But Boston surgeon and New Yorker writer Atul Gawande made the case for locally driven reform this morning at a health care quality colloquium at Harvard.  Communities, he said, need to find ways to create working systems out of the complex, fragmented elements of medicine.

“Our deepest struggle in medicine in this wake of health reform –we can imagine that it is money or the rules and regulations that exist or yet to come down,” he said. “But if you watch the day to day experience of what it is to take care of people, you realize that the deepest root of our struggle is the complexity of what we are trying to pull off. “

Health care workers are surrounded by tests of their ability to handle the complexity that comes in the form of 13,600 diagnoses, 6,000 drugs and 4,000 procedures.  And, he said, they are trying to do it within a system that was built for a world that had fewer, simpler solutions.

The system evolved in another era when medicine was “small, fragmented and artisanal in nature,” he said. “But the volume and complexity of our discoveries has now reached  a point where it has exceeded our ability as individual artisans to deliver optimal care reliably, safely and without the waste of resources.”

He used the advent of penicillin to make his point. Penicillin seemed like a miracle, he said. It could cure diseases that seemed incurable.

“It was so simple,” he said. “It was just an injection. And it made us imagine that this would be the future of medicine. We were fooled. It made us think that discovery was the hard part and execution would be easy.”

He compared the current execution to a poorly built machine with great parts. The fee for service system has “made us almost giddy in our use of high tech services” at the expense of low profit services like geriatrics, mental health and preventive health.

But, Gawande said that he sees solutions in his reporting on cost and practice pattern variations. The highest costs systems don’t always provide the best care, he said.

“That means there is hope,” he said. “It means that there is something to be learned from what we are doing to make quality and safety better in ways that actually reduce costs.”

Gwande spoke at the National Quality Colloquium,  which is being sponsored by the Jefferson School of Population Health at  Thomas Jefferson University in Phildelphia.

JAMA and Dartmouth on Mammograms <50

Gooz News summarizes an article on the USPSTF recommendation on mammography from the evidence-based medicine group at Dartmouth.  It is part of a group of  commentaries on the topic in the Journal of the American Medical Association — you need subscription or access via a library.

  • Without screening, 3.5 of 1000 women in their 40s will die of breast cancer over the next 10 years (ie, 996.5 of 1000 will not die of the disease).
  • Screening reduces the chance of breast cancer death from 3.5 to about 3 of 1000. In other words, 2000 women between 40 and 49 must be screened annually for the following ten years to save one life.
  • For most women with cancer, screening generally does not change the ultimate outcome; the cancer usually is just as treatable or just as deadly regardless of screening.

While the Dartmouth folks support the recommendations, JAMA also features pieces that question the task force findings, including a piece from Johns Hopkins.

Screening for Cancer Questioned

BHN thinks this it is huge that the American Cancer Society finally admitted that cancer screening sometimes leads to overdiagnosis.

Or did they? This blog item from the Associations of Health Care Journalists notes that ACS backpedaled a day after the NYTimes reported on the society’s change of heart. Check out their links too.  

(Times writer Gina) Kolata’s story was published on Tuesday. On Wednesday, the ACS released a statement from Brawley in which he says the organization stands by its screening recommendations.

Here’s why the mantra  of early detection is a problem. We’ve gotten better at finding cancer but we are not very good at sorting the nasty ones out from the tumors that will never grow. If you have a raging tumor, it doesn’t seem to matter when you find it. And, yes, some malignant tumors –possibly quite a few — never grow.  The concept of early detection was a very successful health campaign. Too bad, in many cases, it was wrong.

Gary Schwitzer of  University of Minnesota School of Journalism believes in evidence-based reporting.  He’s been following the follow-ups on this story and isn’t happy.

New media writer Jeff Jarvis, recently diagnosed and treated for prostate cancer, is writing about screening again: “I say, thank god science for screening.”

 He’s entitled to his opinion. He is not entitled to his own personal version of the facts. He writes: “There is a growing rumble about curtailing screening.”

 No. That is simply wrong. There is no move for “curtailing” screening. There are many, however, who are calling for better and more balanced presentation of the potential harms – not just the potential benefits – of such screening.

The debate over mammography and prostate cancer screening has been around for a while. According to the National Women’s Health Networkfifteen years after the debate about the value of screening mammography first flared up, too many women (and clinicians) still don’t know it’s more complicated than the “early detection is your best prevention” slogan.

The stories of note from the NYTimes. 

 Benefits and Risks of Cancer Screening Are Not Always Clear, Experts Say

Most people believe that finding cancer early is a certain way to save lives. But the reality of cancer screening is far more complicated.

Studies suggest that some patients are enduring aggressive treatments for cancers that could have gone undetected for a lifetime without hurting them. At the same time, some cancers found through screening and treated in the earliest stages still end up being deadly.

As a result, the chief medical officer for the American Cancer Society now says that the benefits of early detection are often overstated. The cancer society says it will continue to revise its public messages about cancer screening as new information becomes available.

And, Gina Kolata’s 10/21 story

The American Cancer Society, which has long been a staunch defender of most cancer screening, is now saying that the benefits of detecting many cancers, especially breast and prostate, have been overstated.

It is quietly working on a message, to put on its Web site early next year, to emphasize that screening for breast and prostate cancer and certain other cancers can come with a real risk of overtreating many small cancers while missing cancers that are deadly.

“We don’t want people to panic,” said Dr. Otis Brawley, chief medical officer of the cancer society. “But I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.”

As far as mammography goes, Breast Cancer Action has been all over this. In honor of Breast Cancer Awareness month, check out their “Think Before You Pink” campaign while you’re at it.

Health reform, wired and unwired

There was a State House hearing scheduled today on bill to establish  a single payer health care system in the state. BHN missed it and can’t find any reports. We’ll keep looking. Here’s the background from Mass Care.

We are going to try to hit this wired health care meeting,  which takes place tomorrow and Friday at the Park Plaza.    

Up from Crisis: Overhauling Healthcare Information, Payment and Delivery in Extraordinary Times

Healthcare will have its renaissance when it moves beyond the hospital and clinic and into the day-to-day lives of patients and consumers. The Connected Health Symposium asks how information technology — cell phones, computers, the Internet and other tools — can help people manage chronic conditions, maintain health and wellness, and age with independence. Please come to Boston in the fall, as all of us join the issues of real change in 2009

We’ll try to get the low down on this early morning speech.

Healthcare Reform, Payment Reform, and the Implications for Connected Health by Stuart Altman, of the Heller School at Brandeis University. He’s been up close for health reform efforts through at least five presidents.