TIME Cancer

The Cost of Chasing Cancer

Betty Daniel, right, of Chicago, gets her routine yearly mammogram from Lead Mammography Tech Stella Palmer at Mt. Sinai Hospital in Chicago, February 15, 2012.
Betty Daniel, right, of Chicago, gets her routine yearly mammogram from Lead Mammography Tech Stella Palmer at Mt. Sinai Hospital in Chicago, February 15, 2012. Heather Charles—Chicago Tribune/MCT/Getty Images

Why excessive screening can cause unintended harm, stress and waste

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 a 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 CT scan–a screening test used to detect tumors–that revealed a cyst on his pancreas. Some 3% of people have these cysts, and they are rarely problematic. Based on the cyst’s size and features, there was no clear answer as to what to do about it, but he was given options.

The patient tossed and turned at night, agonizing over stories of pancreatic-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 no threat to his health. The operation was supposed to cost $25,000 and require eight weeks off work. But the toll was much greater, including a debilitating surgical complication.

I thought, This is why he shouldn’t have had a CT scan in the first place. Screening made him sick.

New research finds 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 ages 40 to 59. Following more than 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. 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. Another large study found that among low-risk adults, taking a daily aspirin–a recommendation hammered into me in medical school–can cause significant gastrointestinal or cerebral bleeding that offsets any cardiac benefits. Doctors are also re-evaluating calls for regular prostate-specific antigen tests and surgical colposcopies after “borderline” Pap smear results because of the risks of chasing false positives and indolent disease.

The problem of unintentional harm is far bigger than many suspect. The Office of the Inspector General for the Department of Health and Human Services reports that among Medicare patients alone, it contributes to 180,000 deaths annually. On a national level, if unintentionally harming patients in the process of trying to improve their health were a disease, it would rank as the No. 3 cause of death in the U.S., using Centers for Disease Control and Prevention stats.

In this era of rising medical prices, cutting waste should be the top priority, especially when that waste pulls doctors away from the important work of caring for sick patients. A 2012 Institute of Medicine report concludes that Americans spend as much as one-third of their health care dollars on tests, medicine, 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. The campaign so far includes more than 60 doctors’ societies.

Reducing overdiagnosis and overtreatment will require broadening medicine’s focus beyond hunting and killing disease to sound research and education on appropriate care. We all must come to grips with the public’s expectation for more medicine. New research is capturing what individual stories, like that of my patient, have been trying to teach us: we have a quiet epidemic of unnecessary, costly and sometimes harmful medical care.

Makary is a cancer surgeon at Johns Hopkins Hospital and an associate professor of health policy at the Johns Hopkins Bloomberg School of Public Health

TIME public health

The Dangers of Hunting for Cancer

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.

(MORE: What Now? 4 Takeaways From the Newest Mammogram Study)

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.

(MORE: Breast Cancer Screening Isn’t Going Away—At Least Not Yet)

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.

TIME

Surgeon: What They Don’t Teach in Med School

Tonsillectomy Brain Dead Girl
Jahi McMath Courtesy of McMath Family and Omari Sealey / AP

When serious complications arise, empathy and communication can be the difference between acceptance and a dangerous false hope

As the world watched the brutal struggle between the family of Jahi McMath and her doctors after the 12-year-old’s brain-death complication from a tonsillectomy, I was reminded of how hard it is to approach families about dying patients. Many years ago, I was the doctor whose patient had taken an unexpected turn for the worse. Medical education was notoriously as devoid of information about miracles and comas as it was of eye contact and the art of using plain English.

There was one class in med school on how to talk about death and dying and behavior issues in medicine. But the class was sandwiched between hard-science classes with frequent exams that were the focus of nearly every student. The med-school culture — fostered by the testing system and residency competition — rewarded good grades, not self-betterment of behavior skills. Don’t get me wrong, we all wanted to be empathic master communicators with our future patients, but to get there, spending time on this everyone-will-pass class meant a competitive disadvantage next to classmates focused on acing anatomy and physiology.

(MORE: Brain Death Really Is Death)

Years later, I’d forgotten those communication skills when I desperately needed them. It was after a routine operation in which a fatal, 1-in-1,000 complication occurred. I felt horrible, questioning whether I was at fault or it had been an unavoidable outcome, perhaps one I should have warned the patient about more specifically.

Colleagues assured me that it was not my fault, but the suspicion tore at my confidence as I managed the patient’s rocky course in the ICU. I tried to limit my emotional involvement so it would not impair my decisiveness. I reflexively asked myself if there was a textbook that could instruct me on this important balance.

I decided to take the patient back to the operating room in an attempt to save her. We quickly rolled her bed in that direction, but her family asked me to stop in the hallway for 15 seconds to put their hands on me and pray for me. The patient was sedated, but they whispered goodbye in her ear, sobbing, not knowing if they would ever see her alive again. During the re-exploration surgery, I considered every technical option as to how to manage the complication. Finally, I called a colleague to assist me since he had a fresh perspective on the case. He agreed with what I was doing and refreshed my stamina.

(MORE: Viewpoint: Why Brain Death Isn’t An On-Off Switch)

After surgery, tragically, the patient kept getting sicker, and I felt more and more consumed by the details of her hourly decline. Nothing else in the world seemed to be going on — not family obligations or personal deadlines. The patient’s mother begged me to do everything, even more surgery.

It was hard to be honest about the outlook, but I told her that further surgery would not offer any new hope. The next day, it was clear that the patient was nearing brain death. For the next few days, the family had hope, but gradually, in the context of a strong trust in the hospital and our team, they digested what we told them — she had suffered too much irreversible injury and was not going to live. We did everything to ensure that she was not in pain. She died with dignity in the arms of her family.

There is a lot we don’t know about Jahi’s case. Given the missteps of the modern medical profession, I understand the skepticism some may have, especially in the difficult time after a family has lost a daughter to a fatal complication of routine surgery.

I am confident that the doctors did everything they could — medically — to help Jahi. But I also know that the medical schools that teach us about respirators and brain death should also teach us about hand-holding and winning trust.

When a procedure goes fine, a good bedside manner can be a luxury. When serious complications arise, empathy and communication can be the difference between acceptance and a dangerous false hope.

MORE: Study Suggests Way of Preventing Patients from Waking During Surgery

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