The persistence of low-value services

CaptureAnalysis from Health Leaders Media:

Turns out, it’s not so easy to make wise choices about healthcare. Several new studies find that, even with urging, doctors and patients are having a hard time passing on low-value services, including many identified in the Choosing Wisely campaign.  

Not that it should be a surprise. You don’t need an MD to know that change is difficult.

The specialty societies of the Choosing Wisely campaign have offered up a menu of low-value services they suggest patients can live (well) without. The trick is to convince providers and patients to abandon superfluous old-reliables and “might-as-well” tests. They waste money and can do more harm than good.

Somehow, the message isn’t getting through…

And this release today on the ACOG meeting mentioned in the story:


Breast Cancer Screening Conference Addressed Mammography Guidelines

Washington, DC – More than 50 stakeholders in women’s health convened on the 28th and 29th of January, 2016, at the headquarters of the American College of Obstetricians and Gynecologists (ACOG) to discuss recommendations on mammography for breast cancer screening. Participants reviewed current data and provided perspective on the interpretation of the data and resultant recommendations for breast cancer screening.

 

The primary issues addressed at this conference included when screening should be initiated, how frequently mammography should be performed, and if there is a point in a women’s life at which mammographic screening may no longer be beneficial. Although clearly important, other aspects of breast cancer screening – including the role of clinical breast exam and screening for high-risk women or those with dense breasts – were determined to be beyond the scope of this conference.

 

Participants in the conference included representatives from the United States Preventive Services Task Force (USPSTF), the American Cancer Society, the National Comprehensive Cancer Network (NCCN), the American College of Radiology, the American College of Surgeons, the American Academy of Family Physicians, the American College of Physicians, and ACOG. In addition, representatives from more than 22 other organizations representing women’s health care providers, radiologists, patient advocate organizations, and allied women’s health professional communities participated in the conference. Furthermore, patient representatives also provided valuable input.

 

The participants will continue the efforts at addressing breast cancer screening recommendations. It is hoped that the outcome of these conversations will help to improve informed decision-making among women and their health care providers.

 

 

 

 

 

DCIS, female “viagra” and other disturbing women’s health news

Big news in women’s health this week. Good news? Depends on how you see it.

The NYTimes reports that surgery for early stage not-quite breast cancer is pretty much useless. Not shocking since NCI decided that DCIS shouldn’t even be called “cancer.

They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.

Here’s what the editorial on the JAMA study says:

The original goal of mammographic screening was to identify invasive cancers at the earliest stage, because of the superior prognosis of stage I cancers. Prior to the advent of screening, ductal carcinoma in situ (DCIS) made up approximately 3% of breast cancers detected. As we pushed to find smaller and smaller cancers, and targeted calcifications instead of just masses, we began to identify DCIS more frequently. Now DCIS accounts for approximately 20% to 25% of screen-detected breast cancers. The cells that make up DCIS look like invasive cancer both pathologically and molecularly, and therefore the presumption was made that these lesions were the precursors of cancer and that early removal and treatment would reduce cancer incidence and mortality. However, long-term epidemiology studies have demonstrated that the removal of 50 000 to 60 000 DCIS lesions annually has not been accompanied by a reduction in the incidence of invasive breast cancers.1 This is in contrast to the experience with removal of colonic polyps and intraepithelial neoplasia lesions of the cervix, in which the removal of precursor lesions has led to a decrease in the incidence of colon and cervical cancer, respectively.2 We now know that breast cancer encompasses a range of behaviors, from aggressive to indolent; the latter are more likely to surface with screening.3 The analysis of Narod et al4 fuels a growing concern that we should rethink our strategy for the detection and treatment of DCIS.

In this video from Dana Farber, Dr. Eric Winer says doctors need to be clear with patients about the reality of DCIS. “What this is all about is conversations between doctors and patients.” Still, he describes surgery as the standard of care.  Will that change? Despite evidence the lumpectomy is as effective as mastectomy, many women still choose the latter.

Also, the FDA approved so called “female viagra” Here’s the benefit: women taking flibanserin reported between 0.5 and one more sexually satisfying event per month, compared with women taking a placebo.

Here’s what Boston-based  OBOS had to via a guest post on an FDA hearing.earlier this summer.index 

Liz Canner, a filmmaker who produced the documentary, “Orgasm, Inc.,” which examines the search for a female sexual enhancement drug, said the company had “deceived women into taking a drug that doesn’t work better than drinking a glass of wine or two, and could end up killing us.”

“To approve this drug would set the worst kind of precedent: that companies that spend enough money can force the FDA to approve useless and dangerous drugs,” said Dr. Adriane Fugh-Berman of Georgetown University.

More than 30 of those who testified — including health-care providers and a number of women who had participated in the trials — urged the panel to support the drug. One provider stood at the microphone in awkward silence to illustrate how little she has to offer her patients with low sexual desire.

“I want to want my husband, it is that simple,” Amanda Parrish, a mother of four from Nashville, told the panel. “For us, flibanserin is a relationship-saving and life-changing drug.”

Here’s another POV from North Shore psychology blogger Dr. Daniel Carlat;

Flibanserin (brand name Addyi) has just received a controversial and complicated FDA approval for the treatment of low sex drive in women. There’s a lot of outrage in the blogosphere, much of it centered on the lobbying of the FDA by disease advocacy groups.  I agree that this politicization of what should be a scientific process is embarrassing to both Sprout and its supporters. Nonetheless, I’m not nearly as hard on flibanserin as some of my colleagues.

However, the does agree with this statement:

Adriane Fugh Berman said it best as quoted by the New York Times: Flibanserin is a “mediocre aphrodisiac with scary side effects.”
 

2 Boston studies: Breast cancer costs and medical records benefits

After pushing mammograms for years, breast cancer advocates have had a hard time pulling back. Still the evidence keep piling up that message about surviving breast cancer is more complicated than early detection.  What this study by Boston researchers doesn’t measure: the scores of women who say — If there’s a chance it’s cancer, I want to know.  From the AP, in the back pages of the Globe A section; buried in the web site.

Sharpening a medical debate about the costs and benefits of cancer screening, a new report estimates that the United States spends $4 billion a year on unnecessary medical costs due to mammograms that generate false alarms, and on treatment of certain breast tumors unlikely to cause problems.

On a lighter note, another study centers on the benefits of giving patients their own records. From the NYTimes.

ONC_PSA_BannerAd_300x250_Red_Button_1Some of the most advanced medical centers are starting to make medical information more available to patients. Brigham and Women’s, where Mr.  (Steven) Keating had his surgery, is part of the Partners HealthCare Group, which now has 500,000 patients with web access to some of the information in their health records including conditions, medications and test results.

Other medical groups are beginning to allow patients online access to the notes taken by physicians about them, in an initiative called OpenNotes. In a yearlong evaluation project at medical groups in three states, more than two-thirds of the patients reported having a better understanding of their health and medical conditions, adopting healthier habits and taking their medications as prescribed more regularly.

Here’s the Globe’s take.

Some patient advocates have been pushing for this for years, and having a little fun with it.

Where to put health stories in the paper and why it matters

The Boston Globe has taken to playing stories on medical research findings — like today’s digital mammography report —  on Page 2. For the writer, good play, but not great. To the reader, this suggest important, but not front page important.  This is commendable – often stories about complicated or incremental developments make  the front page,  giving readers the false impression that they need to stop eating eat this food or start taking that drug.

photo (3)A front page story on a research paper suggests a major development. (Good health writers try not to use the hyperbolic word “breakthrough.”)  So, the 1A Vertex story on a new CF drug rates as both a business and medical story. It could be life changing for people with cystic fibrosis and for the company’s bottom line, which is suffering from the arrival of new Hep C drugs. What we don’t like about the CF story – it could use a comment from someone not involved in the research. It’s a business story, so they seek out an analyst,  but he gushes. And his agenda is investing, not health.  It needs a CF scientist or clinician not involved in the study. Still, we get how hard it is to pull these stories together on deadline.

The Page 2 story on digital mammography offers such a comment. The JAMA article was accompanied by an editorial from Dr. Etta Pisano, a breast imaging radiologist at the Medical University of South Carolina who has done a lot of work in this area. Could have been a bit higher in the story but it works:

“There’s a debate about the harms of screening and overdiagnosis of breast cancers from mammograms and to me, this doesn’t resolve that,” she said.

Want to see how it shouldn’t be done? Check out the Health News Review. The list of stories that resorted to sensational language – breakthrough, game-changer, best way of detection, any woman should have this, lifesaver – was long.”

What’s the Boston play online? By late morning, neither story was high on the home page. At least you can click on the Business section from the home page. Health? Still no home on the home page. Click on “News” to find the link.

 

Another study questions benefit of mammograms, via Globe, Times

The Globe isn’t sharing much with Boston.com these days. But, you can still access most of the blogs.

Mom, post breast cancer

Mom, post breast cancer

Today’s Daily Dose is on the mammography debate. We all thought early detection was key. For breast cancer, maybe not. 

In a research finding that will add to doubts about the value of breast cancer screening, Canadian researchers determined that women ages 40 to 59 who had yearly mammograms enjoyed no added survival benefit up to 25 years later compared with those who skipped the screening X-rays….

The latest finding, published Tuesday in the British Medical Journal, confirms earlier results from the Canadian trial, which first came out two decades ago and is unlikely to discourage many doctors from recommending screening…

But the researchers also determined that 22 percent of breast cancers initially detected on mammograms in the early 1980s were “over-diagnosed”—meaning they never would have been found otherwise and would not have become life-threatening. Most of these women had surgery to remove these tumors which, in hindsight, was unnecessary…

Such findings haven’t, though, swayed the opinions of most women and doctors, who remain more concerned about a life-threatening cancer going undetected than a harmless one being over-treated

Two local docs defend the procedure:

“Mammography is an imperfect test at best, but at this point, it’s the best test we have,” said Dr. Ann Partridge, a breast oncologist at Dana-Farber Cancer Institute. She and others highlighted some potential methodological flaws of the Canadian study.

For example, Partridge said, technology has improved significantly over the past 30 years with X-ray machines and digitized film that yield clearer images….

Some radiologists have sharply attacked the study investigators, accusing them of having a bias against mammography by designing a study in which the control group of women in their 50s received breast exams performed by skilled nurses every year instead of mammograms.

“The principal investigator set out to prove that all you needed to do was a physical examination,” said Dr. Daniel Kopans, director of breast imaging at Massachusetts General Hospital, in an e-mail responding to the new study finding. “The nurse examiners were highly trained while the radiologists and technologists [who performed the mammograms] had no training.”

Not everyone is sticking with mammography. The advocates at Breast Cancer Action have long questioned its usefulness.

And, the New York Times story offered this telling quote:

“It will make women uncomfortable, and they should be uncomfortable,” said Dr. Russell P. Harris, a screening expert and professor of medicine at the University of North Carolina, Chapel Hill, who was not involved in the study. “The decision to have a mammogram should not be a slam dunk.”

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.

Goodman on mammography: Policyspeak v. pink ribbons

Globe-based national columnist Ellen Goodman writes today about how badly the USPSTF delivered the message on the limits of mammography in women under 50. She agrees with their recommendations. She just thinks the panel was blindsided by extremely angry women who are not willing to reconsider the notion that early detection is key to cancer survival.  Then there was the anti-health reform “guidelines = rationing/death panel”  crowd.

This was never going to be an easy message. The breast cancer research is more complex and controversial than the cervical cancer research that was released just days later with recommendations to delay and reduce pap smears. But nevertheless, this perfect storm created a perfect case on how not to deliver a public health message.

It’s important because – and I say this as someone whose mother, aunt, and sister have all had breast cancer – the task force had a strong story to tell. The benefits of mammography for younger women have been oversold. As Laura Nikolaides of the National Breast Cancer Coalition and a cancer survivor says, “People have been doing mammography as a security blanket: If you have a mammogram, you won’t die of breast cancer. We wish that were true.’’ The biology of the tumor – how aggressively it grows – is now judged more important than the size at which it was discovered. And the terrible reality is that we haven’t done much to change the survival rate of younger women who get this disease.

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