Why more screening is not always better
As a surgeon, I’m trained to crush cancer. For many years, every tumor I palpated and family I counseled drove me to hunt for cancer with vengeance, using every tool modern medicine has to offer. But recently, one patient reminded me that the quest to seek and destroy cancer can produce collateral damage.
The patient’s story began with a full-body CAT scan, a screening test used to detect tumors, which revealed a cyst on his pancreas. Some 3 percent of humans have these cysts and they are rarely problematic. Based on his cyst’s size and features, there was no clear answer as to what to do about it, but he was given options.
(MORE: Screening Cancer)
The patient tossed and turned every night, agonizing over stories of pancreas cancer tragedies, consumed by the dilemma of whether to risk surgery to remove the cyst or leave it alone. The conundrum strained his marriage and distracted him from his work.
Months before I met him, the patient underwent the surgery, which revealed that the cyst was of no threat to his health. The operation was supposed to cost $25,000 and eight weeks out of work. But the toll was much greater, including a debilitating surgical complication.
I thought: this is why he shouldn’t have had a CAT scan in the first place. Screening made him sick.
New research is finding that some health screening efforts have gone too far. A recent study found that yearly mammograms do not prolong the lives of low-risk women between the ages of 40 and 59. Following 89,000 women for 25 years in a randomized controlled trial (the gold standard of science), the study is as methodologically impressive as they come. In fact, in research terms, the report has more scientific merit than any medical study of chemotherapy. As hard as it is for our pro-screening culture to believe, the data are clear. We are taxing far too many women not only with needless and sometimes humiliating x-rays, but also with unnecessary follow-up surgery.
The annual mammogram is not the only vintage medical recommendation under scrutiny recently. Another large study found that among low-risk adults, a daily aspirin — a recommendation hammered into me in medical school — kills as many people from bleeding as it saves from cardiac death. Doctors are also re-evaluating calls for regular prostate-specific antigen (PSA) tests and surgical colposcopies after “borderline” Pap smears because of the risks of chasing false positives and indolent disease.
The bad news is that the problem of unintentional harm is far bigger than many people suspect. The Office of the Inspector General for Health and Human Services reports that among Medicare patients alone, it contributes to 180,000 deaths annually. On a national level, unintentionally harming patients in the process of trying to improve their health now ranks as the number three cause of death in the U.S. — ironically just after cancer.
In this era of rising medical prices, manifesting as higher deductibles and co-pays, cutting waste should be our top priority, especially when that waste pulls doctors away from the important work of caring for sick patients. A 2013 Institute of Medicine report concludes that Americans spend as much as one-third of our healthcare dollars on tests, medicines, procedures, and administrative burdens that do not improve health outcomes.
The patient I met also taught me about another negative outcome — one that does not show up in the national stats: emotional trauma from false alarms. The patient recounted feeling tormented by the idea that he might be harboring a “precancerous” time bomb. His distress arose not from cancer, but from medicine’s limited ability to interpret a normal variation of anatomy discovered by new technology.
The good news is that a grassroots movement within medicine is identifying unnecessary tests and procedures to educate doctors and the public about them. The American Board of Internal Medicine Foundation has been asking medical specialty associations to name the five most overdone tests and procedures within their specialty (choosingwisely.org.). The campaign has recently expanded and now includes 50 doctors associations.
Reducing over-diagnosis and over-treatment will require broadening medicine’s focus beyond hunting and killing disease to sound research and education on appropriate care. Medical training should also examine why our culture prefers CAT scans over physical exams, and pills over prevention.
Finally, we all must come to grips with the public’s expectation for more medicine. New research is capturing what individual patient stories, like that of my patient, have been trying to teach us: We have a quiet epidemic of unnecessary, costly, and sometime harmful medical care.
Dr. Marty Makary is a cancer surgeon at Johns Hopkins Hospital and associate professor of health policy at the Johns Hopkins Bloomberg School of Public Health.