Friday, June 4, 2010

The Evils of Screening

The other day, the Girl wanted to try her fancy ophthalmology equipment on me, before unleashing it on the population of Southern Zealand. She checks vision and refraction with a fancy machine, checks for strabismus and color blindness and then takes a photo of the retina. I cruised through the first parts of the exam and was diagnosed with perect vision and refraction. Ahh. Of course I knew that doctors are immune to illness, but confirmation is always nice.

Then she took a high-resolution photo of my left retina. No signs of diabetes, hypertension, age-related macular degeneration or other disease. She focused in on my right eye, the blinding flash went off and, almost before I could see again, she exclaimed "huh?". She took another picture to make sure what she was seeing wasn't an artifact, but whatever she had seen was apparent in both photos. She let me walk around to the doctor side of the room and see what had surprised her. There was a little crescent-shaped brown lesion between my optic nerve and my macula. She had no clue what it was, but it wasn't supposed to be there.

The Girl being a lowly resident, I hoped her attendings, including a renowned retinal speicialist, would be able to tell her it was nothing to worry about. Instead, after getting multiple opinions, she told me that it was "most likely not cancer" and that it might be a scar or toxoplasmosis. The advice was for me to get it checked out. How, I asked, followed by a pregnant pause. By getting a new retinal photo in a few months. Good thing I am married to the woman doing a population study using retinal photography, huh?.

Or maybe not. Ironically, I have always told the Girl that she has to worry about the incidental finding on her screening exams. She plans to have a clinic day a week, dedicated to the patients with newly discovered disease. Or at least to the ones with disease beyond the scope of a regular ophthalmologist. It has been a complete unknown how many patients she would have to work up through that clinic, and what problems they will have. Thing is, no one has ever done a study like hers before. Right now, her only patient is me (and my odd lesion that's probably not cancer).

Her study starts on Monday.

Screening for disease is an accepted medical practice in clearly defined areas of medicine. Pap smears, colonoscopies (or at least sigmoidoscopies), cholestoerol and blood pressure screening have solid data behind them. A yearly TSH, checking for thyroid disease, might; I am not sure. The screening exam known as the annual physical exam has no data but is still performed in some parts of the world.

Then we have the controversial modes of screening, PSAs and mammography. Honestly, if one cuts out emotion, these tests would have a place in medicine, but they wouldn't be used in population screening. Some studies have shown no benefit, but considerable harm; others have found a small benefit, but considerable harm.

Screening is a huge industry. Take a woman, who carries a small early cancer that most likely will disappear on its own. Imagine the money involved in the follwing process: first she get s mammogram, where a density is seen. Then, she gets an ultrasound or maybe an MRI. A biopsy shows cancer and a lumpectomy is performed. She may get adjuvant radiation and chemotherapy and almost certainly hormone treatments for five years. That's a lot of money. And, a woman in her 50s with no other health problems, is a perfect patient. She has good insurance, shows up on time, pays her bills and has no annoying questions about other health problems.

Drug companies and makers of medical equipment make tons of money on this. Every time a patient is brought into the sick group, it's a boon for the industry. Most physican opinion leaders are sponsored by these companies and the studies conducted by them are sponsored by the same companies.

Many studies have shown no benefit of PSAs and mammography but, interestingly, people aren't happy to hear this fact. Well, some men are happy they don't have to worry about PSAs (and some aren't), whereas most women all determined to get their mammograms. The typical news release talks about a study showing no benefit, as though the result is controversial. Experts then talk about all the limitations of the study. It's rarely mentioned that the experts are sponsored by the drug companies. Sometimes women, whose "lives were saved" by screening, comment too.

And I think there is the rub. The men and women, who have "been saved", are hard to ignore. Of course, out of a hundred women with minimal cancers at diagnosis, only very few (if any) have been saved statistically. But we can't tell who is who. The 98% of women with parts of their breasts missing, having gone through radiation, chemo and hormone therapy, would have done just fine without their mammograms. Of course, we tell them they have been saved. Who the heck wouldn't say that? I have done that over and over again, myslef, and I'm not sponsored by anyone; it's just human nature to paint an optimistic picture.

Drug companies are everywhere. At my previous department, the makers of the different hormone treatments, came to visit all the time. I should say that chemo and radiation are both pretty cheap, but the hormone treatments, including anti-estrogen therapies, aren't. They bought fancy lunches, paid the attendings well for speaking to patient groups and invited all of us on trips to various conferences. Needless to say, as doctors make less money these days, the companies are very influential. I know an MD/PhD, who works in endocrinology, which is generally not very well paid. I imagine he makes more money doing drug talks than he does working as a doctor. And he is the one making guidelines for the hospital about when to use which drug. He is a nice guy, but does anyone really think he isn't biased?

So we have patient organizations, doctors, hospitals, drug companies and makers of medical equipment all in favor of screening that has minimal or no effect. No politician or even insurance company will dare come out against screening.

Imagine a pill that prevented an occasional cancer. Some studies even showed it prevented no cancers. It had horrible side effects, including severe anxiety, humiliation, pain, the loss of a prostate, impotence and incontinence. And it was supremely expensive. Would that pill ever get approved? Then what is it about PSA screening that makes it acceptable?

I worry about the future. People are getting screened with CT scans, sometimes out of trailers in parking lots. This screens for atherosclerotic heart disease and aortic aneurisms, and a lot of incidental findings better left alone. Every time a diagnosis is made, a work up plan is formulated and a medication is started, someone is making big bank on it. The industry wants people sick; that's just the way it is.

Take a field, where no one is making any money: old folks with multiple medical problems. Care is getting so fragmented that an old patient often sees 6 specialists, who treat "their" organ with disregard for the overall picture. Having been briefly in primary care, I can testify to the fact that being the quarterback on such a patient is impossible. Often, the patient complains of fatigue, pain or general decline. Each specialist points out that their organ is doing well and generally presents an overly optimistic picture to the patient. It takes a brave and skillful family doctor to cut through the clutter, start reducing meds and discuss the fact that old age is cathing up to the patient.

Reimbursement is extremely poor in these complicated old patients, so there is little incentive to improve care. Many folks have miserable deaths, because there was no time and money to formulate a living will or simply have a talk about what the patient's wishes were. A fraction of the cost of screening could sponsor the palliative care programs and multi-disciplinary meetings that are so sorely missing.