Re: Healthcare: 38% Favor, 56% Opposed

On Tue, 24 Nov 2009 18:50:51 GMT, bswinca@xxxxxxxx (Ned Niws) wrote:

On Tue, 24 Nov 2009 06:08:21 -0800, Rita <Rita@xxxxxxxxxxx> wrote:

On Mon, 23 Nov 2009 22:51:59 -0800, El Castor <No_One@xxxxxxxx> wrote:

Right at the
climactic moment, we hear about eliminating mammograms for women in
their 40's -- which I believe many of us see as a shadow of rationing
to come. How many in this group know a woman who was diagnosed with
breast cancer in her 40's? I do.

I have been following this debate and looked particularly for the
scientific ratinale behind the change in recommendations."

I found this article in the LA Times Science section:

latimes.com
SCIENCE

Cancer screening: What could it hurt? A lot, actually

Routine cancer testing saves lives, but it also leads to biopsies,
surgeries, radiation, even deaths that otherwise would not have
occurred. But experts' reevaluations are met with public angst.


By Karen Kaplan

November 21, 2009

It seemed like a good idea at the time.

In 1984, Japan began screening the urine of 6-month-old infants for
neuroblastoma, the most common type of solid tumor in young children.
The test was simple and could show signs of cancer long before
clinical symptoms arose.

Hundreds of infants went through the ordeal of diagnosis and
treatment, but it didn't reduce the number of tumors, including deadly
ones, found later. Almost none of the tumors caught by screening
turned out to be dangerous -- and more of the screened children died
from complications of surgery and chemotherapy than from the cancer
itself.

In 2004, health officials ended the program.

The United States is grappling with the same type of problem today.
After decades of focus on the upside of cancer screening, public
health experts are increasingly reevaluating the wisdom of
administering routine cancer screening tests to millions of
asymptomatic people.

Though screening certainly saves lives, recent studies make it clear
that it also leads to biopsies, surgeries, chemotherapy and radiation
-- even some deaths -- that otherwise would not have occurred.

That screening has a downside is not easy to accept, as evidenced by
the furor over this week's recommendation from the U.S. Preventive
Services Task Force that most women wait until age 50 to start routine
mammograms, and then get them only every other year.

Though the decision was based on new scientific evidence that many
more women are harmed than helped by annual tests starting at age 40,
it was swiftly attacked by physicians and policymakers who said they
would ignore it.

The message that we're over-screening for cancer isn't necessarily a
welcome one to the American public either.

A whopping 87% of U.S. adults believe that routine screening is
"almost always a good idea," and 74% believe early detection saves
lives "most or all of the time," according to a 2004 survey in the
Journal of the American Medical Assn.

Most said they'd continue to get their screening tests even if their
doctors advised against it.

Indeed, in the days after the task force released its mammogram
recommendations, breast cancer survivors railed online against what
they saw as the notion that their lives were not worth saving.

Part of the outcry stems from the fact that so many people know
someone who was diagnosed with breast cancer in her 40s and appeared
to respond to early treatment. It's natural to think of those women as
the ones who would be hurt by a reduction in screening, psychologists
say.

We're not as well equipped to weigh the risks and benefits of the
population at large.

"We think, 'I'm sure glad my sister or my best friend got that done,'
" said Julie Downs, director of the Center for Risk Perception and
Communication at Carnegie Mellon University in Pittsburgh.

Also complicating matters is that it's easy to identify cancer
survivors whose tumors were caught by screening, but it's nearly
impossible to put a face on the woman or man who is hurt by
over-screening.

Patients are also reluctant to give up on the idea that they can
control their medical destiny through proactive measures, said Nancy
Berlinger, a healthcare bioethicist at the Hastings Center, a research
institute in Garrison, N.Y.

"Anything that suggests that early detection might not save lives is
going to be deeply disturbing," she said. "It suggests that we can't
do much to help ourselves."

The public's attachment to screening also reflects its faith in
high-tech medicine, said Dr. Len Lichtenfeld, deputy chief medical
officer of the American Cancer Society in Atlanta.

"They want to believe that the new technology is the better
technology," he said. "Sometimes it is -- sometimes it isn't."

The idea that detecting cancers early makes them easier to treat has
been around since at least the 1930s, when doctors began advising
women to conduct breast self-exams.

"That philosophy sounded right, so screenings were implemented," said
Dr. Therese Bevers, medical director of the Cancer Prevention Center
at the University of Texas M.D. Anderson Cancer Center in Houston.

And in many cases, that strategy works. The American Cancer Society
credits widespread use of mammograms for a 2% annual decrease in
breast cancer deaths since 1990. Pap smears have slashed deaths from
cervical cancer by more than 70% since they were introduced in the
1940s.

But finding cancers that respond to early treatment is only one of the
potential outcomes from a screening test. Many tests produce false
positives, prompting additional tests that can be invasive, expensive,
time-consuming and anxiety-inducing.

A study published this spring in Annals of Family Medicine found that
60% of men and 49% of women had gotten at least one false positive
during three years of routine screenings for ovarian, prostate, lung
and colorectal cancer. As a result, 22% of those women and 29% of
those men had an invasive diagnostic procedure, the study found.

Other screening tests produce false negatives, giving patients and
their doctors the incorrect impression that they have nothing to worry
about.

Some detect aggressive cancers whose outcomes aren't improved by early
detection.

And some identify small cancers that grow so slowly they'd never
compromise a patient's health. Many would even go away on their own.

Statisticians and epidemiologists know this for a fact. The problem
is, there's no way to tell which of the tumors are dangerous and need
to be treated and which are harmless and would be best left alone. So
all of them get treated, often aggressively. The medical establishment
calls this overdiagnosis.

"Overdiagnosis is the hardest thing to explain to people," said Dr.
Stephen Taplin, chief of the Applied Cancer Screening Research Branch
at the National Cancer Institute in Washington, D.C. "No individual
woman can know if they're overdiagnosed. They know they have cancer,
and they're scared to death. It's completely justified.

"But if you look at people overall," he added, "there are some people
who suffered that scare unnecessarily. If they had never known about
that cancer, it wouldn't have affected their life."

Such nuances weren't considered when screening tests were implemented.
Many were introduced before their effectiveness had been established
though clinical trails. At the time, doctors didn't see the need. But
experience has prompted them to reconsider.

Take the cancer antigen 125, or CA 125, test that has been used to
screen for ovarian cancer. Women with the disease often have higher
blood levels of this protein, so it seemed to make sense to check for
it in asymptomatic women.

The test was never widely adopted and is no longer recommended for
women at average risk, because other conditions, such as
diverticulitis and endometriosis, can also boost CA 125 levels. And
some patients with the disease have normal levels of the protein.

Many doctors are backing off the prostate-specific antigen test to
screen for prostate cancer now that two influential studies published
this year found that early detection offered little to no benefit in
long-term survival. But the PSA tests did prompt aggressive treatment
that sometimes left men impotent or incontinent.

Some guidelines, including those for cervical cancer, have been
amended to reflect a better understanding of cancer biology. The
American College of Obstetricians and Gynecologists this week
suggested that most women get Pap tests less frequently because it's
known now that cervical cancer progresses slowly, and abnormal cells
often resolve on their own, especially in younger women.

Despite outcry from patients who equate reduced screening with reduced
care, it makes no sense to ignore scientific data that happen to be
unpalatable, said Dr. George Sawaya, a researcher at UC San Francisco
whose studies helped prompt the change in Pap test guidelines.

"It would be much more of a travesty if we didn't change our
guidelines in response to new information," he said.

karen.kaplan@xxxxxxxxxxx

You can make of this what you will. But to assume the \purpose of
the new recommendations is to ration medical care suggests one
is leaping to an unfounded conclusion.

There is no question that North American Health care has leaned
heavily in favor of going farther in doing tests than is really
warranted by the patient's condition.

This is more pronounced in the USA than in Canada because of the more
widespread use of litligation and expensive settlements.

In Canada, the involvement of the government in paying expenses has
resulted in heavy review of the necessity of all kinds of tests and
even procedures.

There are all kinds of things which are now being looked at in askance
and when one reviews the rationale for these apparently redundant
test/procedures, it does raise a lot of interesting questions.

Being Canadian, I do not assume that this is a conspiracy by the
government to manage the demand to fit the supply. Rather I look at
professional medical journals and newspapers to argue the case in
front of the public on the basis of merit rather than fear mongering
and creative manipulation of the news.

It's actually kind of interesting because more and more we are seeing
treatment being defined in terms of Decision Tables (if this and this
then do that and that). These Decision Tables are easily turned into
diagnostic and medical web sites which in turn help us to monitor what
our own individual treatments from our own medical supports.

This stuff on mammogram and pap smears is really good discussion
provided people will filter out the creative invention of false
information and phoney arguments and then consciously err on the side
of humanity.

Unfortunately honest arguments are often outweighed by the hysterics
from lobbyists.

Bruce

Hi Bruce,

"The Fraser Institute's annual survey of hospital waiting lists
released recently showed that total wait time in 2009 is still 73 per
cent longer than it was back in 1993, despite the fact that health
spending per person has increased by 41 per cent since then. Simply
put, the public health care system is still failing Canadians. That
Canadians are required to endure a median wait time of 16.1 weeks from
GP referral to treatment by a specialist in the developed world's
second most expensive universal access health care program should be
considered unacceptable. So should the fact that wait times remain
historically high in spite of substantial increases in health spending
across Canada over time."
http://telegraphjournal.canadaeast.com/opinion/article/864637

Now, if you will excuse me, I have to schedule an annual appointment
with my ophthalmologist.

Ah, I'm back!

I have the appointment -- in less than a week. Being Canadian, I know
you find that routine, and I have to confess that unlike making an
appointment with my primary care physician, which I can do on-line, a
specialist requires that I pick up the phone. )-8
.

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