[Reblog] Could finding more cancer lead us to understand risk factors less?

From an article at the HealthNewsReview.org blog, by Michael Joyce

An opinion piece in last week’s Annals of Internal Medicine argues that just how aggressively we screen for some cancers can actually distort our understanding of the risk factors for a particular cancer, as well as how common we perceive it to be.

The authors describe ‘scrutiny-dependent’ cancers  — those subtypes of cancers often picked up with screening that are commonly referred to as slow-growing, indolent, subclinical, or even as pre-cancerous — and that often don’t progress to cause health problems or shorten lives. Prostate cancer and thyroid cancer are two such examples.

They propose two common ways in which aggressive screening can distort our understanding of these cancers:

• The push for ‘early detection’ leads to more scrutiny-dependent cancers being found which, in turn, gives the false impression of an increased incidence of some cancers.
• Aggressive screening of the family members of someone with cancer means more cancer will be found. This could give the impression of family history being more of a risk factor than it may actually be.
  ….
• Breast cancer found by mammography, ultrasound, or MRI is more likely to be indolent than that found by self-examination. As we screen with more advanced technologies capable of finding smaller and smaller tumors, we will find more cases of cancer but also more cases that don’t develop into cancer. This not only represents overdiagnosis, but can also give the false impression of breast cancer being more common than it really is

…

“In the 80’s and 90’s the prevailing message from the media was screen, screen, screen,” said Brawley. “Only in the past 10-15 years have some reporters begun to question this. And this goes for advocacy groups too, who have an understandable emotional conflict of interest because they care about a particular disease. I know, I work for one. But, both reporters and advocates need to be truthful and accurate about screening. Because people can get hurt.

,,\…
In short, Welch and Brawley firmly believe that screening should be based on rigorously tested evidence. In some cancers that evidence is clear, while for other cancers (‘scrutiny-dependent’ ones) the evidence is lacking. Media messages about cancer screening need to do a better job communicating that uncertainty. 

[Press release] Do no harm: Pediatrician calls for safely cutting back on tests, treatments





http://www.portaldemisterios.com/videos/yt-MyfqSZg3RLw


http://www.eurekalert.org/pub_releases/2014-10/aaop-dnh100314.php

From the October 2014 press release

SAN DIEGO – When parents take a sick or injured child to the doctor or emergency room, they often expect tests to be done and treatments given. So if the physician sends them on their way with the reassurance that their child will get better in a few days, they might ask: “Shouldn’t you do a CT scan?” or “Can you prescribe an antibiotic?”

What families — and even doctors — may not understand is that many medical interventions done “just to be safe” not only are unnecessary and costly but they also can harm patients, said Alan R. Schroeder, MD, FAAP, who will present a plenary session at the American Academy of Pediatrics (AAP) National Conference & Exhibition. Titled “Safely Doing Less: A Solution to the Epidemic of Overuse in Healthcare,” the session will be held from 11:30-11:50 a.m. PDT Monday, Oct. 13 in Ballroom 20 of the San Diego Convention Center.

Dr. Schroeder, chief of pediatric inpatient services and medical director of the pediatric intensive care unit at Santa Clara Valley Medical Center in San Jose, Calif., will discuss some of the reasons why doctors provide unnecessary care (i.e., barriers to safely doing less), including pressure from parents and a fear of missing something.

“We all have cases where we’re haunted by something bad happening to a patient. Those tend to be cases where we missed something,” he said. “We tend to react by doing more and overtreating similar patients.”

He also will give examples of where overuse commonly occurs in pediatrics, such as performing a CT scan on a child with a minor head injury, and the negative consequences.

“You may find a tiny bleed or a tiny skull fracture, and once you’ve found that you’re compelled to act on it. And generally acting on it means at a minimum admitting the child to an intensive care unit for observation even if the child looks perfectly fine,” Dr. Schroeder said. “The term for that is overdiagnosis. You detect an abnormality that will never cause harm.”

Finally, he will suggest ways to minimize overtesting and overtreatment, highlighting the Choosing Wisely campaign. More than 60 medical societies including the AAP have joined the initiative and have identified more than 250 tests and procedures that are considered overused or inappropriate in their fields.

“I’ve devoted much of my research to identify areas in inpatient pediatrics where we can safely do less — which therapies that we are doing now are unnecessary or overkill,” Dr. Schroeder said.

###

The American Academy of Pediatrics is an organization of 62,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. For more information, visit http://www.aap.org.

Related articles

• Prenatal Exposure To Viruses May Cause Type 1 Diabetes And Other Autoimmune Diseases
• Parental misconceptions about concussions could hinder treatment and recovery
• Artificial Sweeteners Mess With Gut Bacteria and May Increase Risk of Diabetes

George W. Bush’s angioplasty: Did he receive the best care? (With Lively Discussion on Pros/Cons of Medical Screening)

 

Polygon Medical Animation – Angioplasty Procedure (Photo credit: Polygon Medical Animation)

 

 

 

 

 

 

 

From the 19 August 2013 Kevin MD article by ALBERT FUCHS, MD

…..

The press coverage of Bush’s angioplasty had frequent questions about the necessity of the angioplasty and the cost of such a procedure. That is precisely not the point, and gives the public the incorrect idea that angioplasties are expensive and beneficial luxuries. BMWs, after all, are unnecessary and expensive, but very nice. And if a VIP gets something unnecessary and expensive, shouldn’t I want one too? The point of the evidence about angioplasties is that in most patients they have no benefit. Focusing on “necessity” misses that point.

It is entirely possible that Bush’s care was flawless. One possibility was that his stress test was extremely abnormal. Such very abnormal tests were excluded from the COURAGE trial, and we have no definitive evidence whether medications or stenting is best in those cases.

The important thing for the public to understand is that VIPs sometimes get terrible care. I’ve personally seen that myself. Physicians often over-test and over-treat celebrities, wrongly thinking that this will protect them from blame for any adverse outcome later. It’s much easier to tell a prominent patient that we will fix your problem with a high-tech and very expensive solution, rather than taking the time to educate the patient that we should start a few very old and very inexpensive medicines which have been proven to save lives. Paradoxically, we’re frequently much more comfortable doing the right thing for patients who will not draw public attention.

……

Read the entire article here

The comments section was very interesting and lively.
Pap testing was one topic.  An excerpt

For those women interested, in my opinion, the best screening program in the world for cervical cancer is the new Dutch program. They’ll scrap their 7 pap test program, 5 yearly from 30 to 60, and offer instead 5 hrHPV primary tests at ages 30,35,40,50 and 60 and ONLY the roughly 5% of women who are HPV+ and at risk will be offered a 5 yearly pap test. (until they clear the virus) This will save more lives and take most women out of pap testing and harms way. (damage to the cervix can mean miscarriages, premature babies, c-sections etc.)

Those HPV- and no longer sexually active or confidently monogamous might choose to stop all further testing. Dutch women are already using a HPV self-test option/device, the Delphi Screener. (also, available in Singapore and elsewhere)
I’ve also, declined breast screening even though that cancer is far more common. Weighing up the risks and actual benefits, it doesn’t get over the line for me. (The Nordic Cochrane Institute brochure on breast screening and Professor Michael Baum’s informative articles and lecture helped me make an informed decision to decline testing)

Speaking generally:

We need to stop telling women what to do and start respecting informed consent. Give women real information on risk and ACTUAL benefit, respect them as competent adults/individuals and offer evidence-based testing that focuses on what’s best for them AND, leave the final decision to women, to accept or decline screening as they see fit.

Related Resources (just a few from many!)

• Cochrane Reviews  (require subscription, available at many academic/health science libraries…however free summaries are here)

systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care. They investigate the effects of interventions for prevention, treatment and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting. They are published online in The Cochrane Library.

Example of a free summary
Screening for breast cancer with mammography (2013) –[scroll down for link to abstract]

• AHRQ-Patient Involvement
• Evaluating Health Information (with links)
• Research papers summarized for us all (links to resources)
• Evidence based practice   (LibGuide with links to tutorials, databases, web resources and more)
• Crunching Numbers: What Cancer Screening Statistics Really Tell Us (National Cancer Institute)
• AHRQ-For Professionals-Prevention and Chronic Care
  • Evidence Based Decision Making
    • US Preventive Services Task Force
      • What Not to Do in Primary Care: Overuse of Preventive Services (  Microsoft PowerPoint version – 1.12 MB )
        Michael LeFevre, University of Missouri-Columbia

Related articles

• UDoTest, HPV Virus Home Screening Kit, Launches In South Africa; Doctor Says It’s ‘More Effective Than A Pap Smear’ (medicaldaily.com)
• Many Docs Don’t Follow HPV/Pap Test Guidelines (nlm.nih.gov)
• Women may not need pap smears every two years according to University of NSW research (abc.net.au)
• Outdated practice of annual cervical-cancer screenings may cause more harm than good (eurekalert.org)
• Why Some Parents Are Refusing HPV Vaccine For Their Children (shotofprevention.com)
• On Self-Advocacy and Paying It Forward (draemadden.wordpress.com)

[Reblog] Ethics of commercial screening tests: choice should be informed by evidence, not advertising claims

 

From the 28 August 2012 post at HealthNewsReview.org

An opinion piece in the Annals of Internal Medicine, “Ethics of Commercial Screening Tests,” makes a strong, clear statement about the problems with many screening test campaigns offered by commercial companies in partnerships with churches, pharmacies, shopping malls or trusted medical organizations. Excerpts:

“Particular concerns about “the use of ultrasonography (for example, ultrasonography of the carotid arteries to assess for plaques and stenosis, ultrasonography of the heel to assess for osteoporosis, and echocardiography) in the direct-to-consumer screening market as a driver of expensive and unnecessary care.

…

When screenings are provided in a church and sponsored by a trusted medical organization, consumers may have a false sense of trust in the quality and appropriateness of services provided. Consumers are generally unaware of the potential harms of screening.

Because of a lack of counseling by these companies about the potential risks of an “abnormal” test result, the consumer is initially unaware that this may open a Pandora’s box of referrals and additional testing to monitor or treat these abnormal findings. Our medical system and society bear the cost of poor coordination of care and additional testing and treatment to follow up on unnecessary “abnormal” screening test results.  That most of these tests are not medically indicated in the first place is left undisclosed to the consumer, nor is there a discussion of potential adverse consequences or additional costs.

…

Advocates of widespread screening may argue that if patients know that they have disease, they will be more likely to engage in behavior modification. However, evidence does not support this hypothesis.

…

We respect patients’ autonomy to make their own medical decisions. However, choices should be informed by evidence, not such advertising claims as, “the ultrasound screenings that we offer can help save your life.” Patients can be coerced through unsubstantiated, misleading statements or omission of factual information into obtaining tests where the actual risk may outweigh the proven benefit. In direct-to-consumer advertising of pharmaceuticals, companies are required to disclose the potential risks of taking a medication. We believe that commercial screening companies should also be obligated to disclose from published guidelines the recommended indications and benefits of testing, as well as the potential risks and harms.”

 

I’ve written about these commercial screening campaigns in the past.

One year ago at this time – the time of the annual Minnesota State Fair – I wrote about how a local TV station co-sponsored a prostate cancer screening campaign.  This year, it does not appear that the prostate screens are being done.  But ultrasounds of the heel to check for osteoporosis – one of the very specific issues highlighted as a special cause for concern in the journal editorial cited above, continue.  KARE-11 TV of Minneapolis states on its website:

“Put your best foot forward and find out your bone density.  Health Strategies will be providing heel scan ultrasound bone density screenings at the fair.”

The TV station promotes this as “Know Your Numbers.”  Maybe they should know the evidence (or lack thereof) for some of what they’re promoting.

Other related past posts:

• Free Throat, Head, Neck Cancer Screenings Promoted Without Full Info

• In the BMJ: “What companies don’t tell you about screening” and “Routine testicular self examination: it’s time to stop”

• Local TV report questions LifeLine Screening tests

 

Related articles

• Annals of Internal Medicine tip sheet for Aug. 28, 2012 (eurekalert.org)
• Question of the Week: STD’s – Test or Just Treat? (jailmedicine.com)
• Prenatal testing: Is it right for you? (zedie.wordpress.com)

 

When a colonoscopy (or other insurance approved screening ) might not be free

From the January 2012 blog posting ,Place the frustration of cost uncertainty on health insurers
by Kevin Pho at KevinMD.com

As we enter 2012, many patients will be changing to new insurance plans.

And for a few, deductibles will be rising.

One thing that’s emphasized in the Affordable Care Act, however, is that preventive services would remain “free.”

However, consider this story of a man, who thought he wouldn’t have to pay for his screening colonoscopy, instead was charged over $1,000 for the procedure.

From USA Today,

Bill Dunphy thought his colonoscopy would be free.

His insurance company told him it would be covered 100 percent, with no copayment from him and no charge against his deductible. The nation’s 1-year-old health law requires most insurance plans to cover all costs for preventive care including colon cancer screening. So Dunphy had the procedure in April.

Then the bill arrived: $1,100.

The reason? During the procedure, polyps were found and rightfully removed. But in doing so, it changed the colonoscopy from a screening procedure to a diagnostic procedure, thus making it applicable to the patient’s deductible.

Such semantics are important, as insurance companies will seize them at every opportunity to pass on costs to both patients and hospitals….

Read the entire article by Kevin Pho

 

Related articles

• Preventive care: It’s free, except when it’s not (goerie.com)
• Preventive care: It’s free, except when it’s not (usatoday.com)
• Loophole in U.S. law means not all preventive care free (ctv.ca)
• Preventive care: It’s free, except when it’s not (sfgate.com)
• Preventive care: It’s free, except when it’s not (seattlepi.com)
• Preventive Care Is Free — Except For When It’s Not (huffingtonpost.com)
• Preventive Care: It’s Free, Except When It’s Not (maboulette.wordpress.com)
• Preventive care: It’s free, except when it’s not (mysanantonio.com)
• Preventive care: It’s free, except when it’s not (seattletimes.nwsource.com)
• Know What to Expect From Colonoscopy Prep (everydayhealth.com)

Dentists Could Screen 20 Million Americans For Chronic Physical Illnesses

 

From a December 2011 press release of New York University

An Opportunity to Identify Diabetes, Hypertension, and Other Chronic Diseases

Nearly 20 million Americans annually visit a dentist but not a general healthcare provider, according to an NYU study published today in the American Journal of Public Health.

The study, conducted by a nursing-dental research team at NYU, is the first of its kind to determine the proportion of Americans who are seen annually by a dentist but not by a general healthcare provider.

This finding suggests dentists can play a crucial role as health care practitioners in the front-line defense of identifying systemic disease which would otherwise go undetected in a significant portion of the population, say the researchers.

“For these and other individuals, dental professionals are in a key position to assess and detect oral signs and symptoms of systemic health disorders that may otherwise go unnoticed, and to refer patients for follow-up care,” said Dr. Shiela Strauss, an associate professor of nursing at the NYU College of Nursing and co-director of the statistics and data management core for NYU’s Colleges of Nursing and Dentistry.

During the course of a routine dental examination, dentists and dental hygienists, as trained healthcare providers, can take a patient’s health history, check blood pressure, and use direct clinical observation and X-rays to detect risk for systemic conditions, such as diabetes, hypertension, and heart disease. ……

Read the entire news article

Related articles

• Barbers: Cut, Shave, Lower Your Blood Pressure (jflahiff.wordpress.com)
• Dentists Could Screen 20 Million Americans For Chronic Physical Illnesses (medicalnewstoday.com)

• NYU study concludes that dentists could screen 20 million Americans for chronic physical illnesses (eurekalert.org)
• Dentists could screen 20 million Americans for chronic physical illnesses: study (medicalxpress.com)
• Dentists Could Fill Gap in Health Care (nlm.nih.gov)

Self-Affirmation May Break Down Resistance to Medical Screening

From the 21 December 2011 News article

People resist medical screening, or don’t call back for the results, because they don’t want to know they’re sick or at risk for a disease. But many illnesses, such as HIV/AIDS and cancer, have a far a better prognosis if they’re caught early. How can health care providers break down that resistance?

Have people think about what they value most, finds a new study by University of Florida psychologists Jennifer L. Howell and James A. Shepperd. “If you can get people to refocus their attention from a threat to their overall sense of wellbeing, they are less likely to avoid threatening information,” says Howell. Do that, and people are more likely to face a medical screening even if it means undertaking onerous treatment and even if the disease is uncontrollable. The findings will appear in Psychological Science, a journal published by the Association for Psychological Science.

The researchers undertook three studies, each with about 100 students of both sexes. In all three studies, they asked the participants to think of a trait they valued; they chose traits such as honesty, compassion, and friendliness. Participants then wrote either about how they demonstrated the trait (expressing self-affirmation) or a friend (not affirming themselves) demonstrated the trait….

Read the entire news article

Related articles

• Self-affirmation may break down resistance to medical screening (medicalxpress.com)
• Self-affirmation may break down resistance to medical screening (eurekalert.org)
• When Are You Too Old For Routine Screening Tests? (aarp.org)
• Breast cancer screening saves lives – but it causes harm, too (telegraph.co.uk)
• African American Communities Face Aids Crisis (socyberty.com)
• Symptom-Based Screening May Improve Detection Of HIV In High-Risk Men (medicalnewstoday.com)