Tuesday, October 12, 2010

Dumb Medicine: Screening for Cancer in Patients already Diagnosed with Incurable Cancer

I used to get sports illustrated, and my favorite column was titled "this weeks sign that the apocalypse is upon us."  Well, today JAMA published the medical equivalent.

Sima and colleagues at Memorial Sloan Kettering used a population based dataset of patients with cancer to compare rates of cancer screening (mammography, PAP smears, PSA tests, colonoscopy) between patients who had advanced, incurable cancer (lung, colorectal, gastroesophageal, and breast cancers) and patients who did not have cancer.  Results
  • Mammography: 9% among patients with advanced cancer vs. 22% among patients without cancer
  • PAP smears: 6% vs. 13%
  • PSA testing: 15% vs. 27%
  • Colonoscopy: 2% vs. 5%
The good news - the rates are not equal.  At least a few docs are thinking enough to not screen patients with advanced incurable cancer for another cancer! 

The bad news - screening rates among patients with cancer are about a third to two-thirds of the rates of patients without cancer!  Keep in mind people need to live about 5 years in order to benefit from cancer screening.  Patients in this study had a life expectancy of less than 2 years at the time they were screened, and less than 5% overall lived more than 5 years.

The biggest predictor of continued screening after diagnosis with cancer was a history of cancer screening before diagnosis.  The authors hypothesize that docs put patients on "autopilot" cancer screening, and then don't stop.  They write:
Furthermore, we hypothesize that neither primary care physicians nor oncologists routinely engage in the difficult discussions that require explanation of why continuation of procedures to which patients have become accustomed to is no longer necessary. There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss. Our findings represent one manifestation of this communication deficit.
Exactly.  We need to train providers to have these difficult conversations, create health systems that flag patients with limited life expectancy who are receiving potentially harmful tests and interventions of little benefit, and educate the public about the harms of overtesting and overtreatment.  The last is critical, because the hue and cry must come from the people - not the doctors - to instigate change.

But change we must.  Because what we're doing is just dumb medicine.  This weeks sign that the apocalypse is upon us.

by: Alex Smith

10 comments:

Eric Widera said...

I am left speechless.

Lindsey Yourman said...

I hoped that upon reading this JAMA article I'd find that the PSA stat (15%!) had been improperly inflated due to a failure to distinguish between monitoring vs. diagnostic PSAs . . . but then I read:

"Cancer screening procedures are assigned
distinct codes for screening and
for diagnosis. We restricted our analysis
to codes that specifically identify
screening tests."

OK, so they tried to distinguish btwn diagnostic vs. screening PSAs. Then I hoped that the authors hadn't accounted for sloppy ICD-9 coding.

Only to read . . .
"Furthermore, we
minimized the potential for mislabeling
procedures ordered as part of establishing
a cancer diagnosis and staging
workup by excluding claims billed
during the first 2 calendar months subsequent
to cancer diagnosis. Consequently,
screening rates for patients
with cancer reflect the tests performed
between the third calendar
month following cancer diagnosis (case
follow-up start date) and death or December
31, 2007, whichever came first
(case follow-up end date)."

Gulp. Almost 1/6 men with an incurable cancer and limited life expectancy, screened for a cancer that was unlikely to ever cause them symptoms . . . but for which a positive diagnosis can cause immediate psychological and iatrogenic-related morbidity. Now I'm speechless.

Patrice Villars said...

Sheesh. I love the head scratcher pic, though.

Tim Cousounis said...

Yet another stirring example of "The Rise and Decline of US Medical Care," in which advanced health care systems become encrusted with powerful interest groups that serve their narrow ends and inefficiency reigns.

CyndiC, RN said...

I think this just shows how too many oncologists are not really talking with their patients about prognosis.

When an MD tells their patient with an incurable disease: "I can do this, I I can do this..." the patients hears: "I can do this to cure you..."

Without those difficult conversations about what kind of illness they actually have, too many patients don't truly even realize that their condition is considered incurable short of those rare miracles--which, in my opinion, happen with or without our interventions...

some people just survive occasionally in spite of us...

Manal B said...

I strongly agree on the importance of training clinicians on handling difficult conversations and phrasing facts and/or potential of treatments to clients. I would also add the importance of training clinicians to handle the issues of "alternative or complementary medicine" intelligently with patients.

Anonymous said...

Can you give an example of handling issues of alternative medicine intelligently vs. unintelligently? I'm a student who has much to learn about this!

g said...

As a hospice and palliative medicine physician this unfortunately is another example of physicians not discussing these issues with their patients, due to their own discomfort. I find that > 90% of the time a patient will say "I know that I am dying, I have just been waiting for my doctor to discuss with me." Many times it brings patients a sense of relief and comfort to be able to have a calm and open discussion with their physician. As professionals and as a society we need to not be scared of death but rather face it straight on is it part of being alive.

Anonymous said...

As a hospice and palliative medicine physician this unfortunately is another example of physicians not discussing these issues with their patients, due to their own discomfort. I find that > 90% of the time a patient will say "I know that I am dying, I have just been waiting for my doctor to discuss with me." Many times it brings patients a sense of relief and comfort to be able to have a calm and open discussion with their physician. As professionals and as a society we need to not be scared of death but rather face it straight on it is part of being alive.

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