Health care’s third rail: Should can­cer screen­ings be cut back?

Austin American-Statesman - - BALANCED VIEWS - Shelly is a colum­nist for the Kansas City Star. bshellykc­star.com.

Three

years ago, a lit­tle­known panel, the U.S. Pre­ven­tive Ser­vices Task Force, el­bowed its way into the na­tional con­ver­sa­tion with a star­tling rec­om­men­da­tion that most women younger than 50 could forgo an­nual mam­mo­grams.

The find­ing stuck a fin­ger in the eye of con­ven­tional wis­dom. A gen­er­a­tion or more of women had come of age be­liev­ing reg­u­lar screen­ing is the best way to pro­tect one­self from dy­ing of can­cer. Ar­riv­ing in the midst of Pres­i­dent Barack Obama’s health care re­form ef­fort, the rec­om­men­da­tion fed into op­po­nents’ con­vic­tion that government was try­ing to force its way into life-or-death de­ci­sions.

Mem­bers of Congress blasted the task force. Doc­tors con­tin­ued to rec­om­mend mam­mo­grams, and women kept get­ting them.

But the find­ings, and the sci­ence be­hind them, did not go away. For more than a decade, mul­ti­ple stud­ies have ad­vanced the ar­gu­ment that rou­tine screen­ing for some forms of can­cer doesn’t pre­vent pre­ma­ture death and may do more harm than good.

The find­ings of a large study re­leased on Thanks­giv­ing Day added more weight.

Re­search in the New Eng­land Jour­nal of Medicine looked at more than 30 years of U.S. health statis­tics. It found that mam­mo­grams are ef­fec­tive at de­tect­ing early stage breast tu­mors, but they don’t re­duce the num­ber of women di­ag­nosed with ad­vanced stage can­cers.

The con­clu­sion was that early de­tec­tion doesn’t save lives. Rather, it prompts mil­lions of women to un­dergo ex­pen­sive, in­tru­sive treat­ment for tu­mors that would never be­come life-threat­en­ing.

Sim­i­lar mixed mes­sages have been sounded to men about screen­ings for prostate can­cer. Stud­ies have found that early de­tec­tion and ag­gres­sive treat­ment of that disease may be un­nec­es­sary, in­ef­fec­tive and risky.

This is the third rail of health care — the sci­ence that no one knows how to come to grips with. Not doc­tors, not pa­tients, not politi­cians.

Is it time to re­think the value of pre­ven­tive screen­ings and cut back on the costly di­ag­no­sis and treat­ment op­tions that come with early de­tec­tion?

Doc­tors and politi­cians can quib­ble with the ac­cu­racy and meth­ods of in­di­vid­ual stud­ies. It be­comes harder to push against their com­bined weight.

And yet four decades of doc­tors’ warn­ings and pub­lic in­for­ma­tion cam­paigns will not be eas­ily un­done. A vast in­dus­try of equip­ment, tech­nol­ogy, ex­per­tise and ad­vo­cacy built around screen­ing and early de­tec­tion won’t be eas­ily dis­man­tled.

Per­son­ally, I would love to skip the an­nual mam­mo­gram. But un­less or un­til my doc­tor ad­vises me to do so, I’m not sure I will. Stud­ies are re­mote; my long-time in­ternist is real.

The big­ger dilemma comes if a mam­mo­gram or a PSA test turns up some­thing sus­pi­cious. Re­search in­di­cates that of­ten a low-tech treat­ment called watch­ful wait­ing is as ef­fec­tive as more ag­gres­sive in­ter­ven­tions. But that’s not how most pa­tients or the U.S. med­i­cal sys­tem are wired.

“It’s al­most as if the ear­lier it’s caught, the more con­flict it causes for the pa­tient,” said Jen­nifer Klemp, a re­searcher and pro­fes­sor at the Univer­sity of Kansas Can­cer Cen­ter.

The same goes for the doc­tor. “The worst fear for a physi­cian is to have to make that call,” Klemp said. “They’re not trained to wait. They’re trained to do some­thing.”

Klemp is hop­ing for sci­en­tific break­throughs that will en­able doc­tors to pre­dict with rea­son­able ac­cu­racy whether an early stage tu­mor will de­velop into a deadly form of can­cer. Un­til then, she and oth­ers on the front lines will con­tinue to tread care­fully in a ter­rain that is more gray than black and white.

“What they say in­tu­itively makes sense,” Klemp said of the stud­ies that seem­ingly call for less screen­ing and in­ter­ven­tion. “But we’re deal­ing with hu­man be­ings.”

A West Lake Hills res­i­dent who cleared what he says were dead ju­niper trees from his prop­erty is ac­cused of vi­o­lat­ing a city or­di­nance and could face tens of thou­sands of dol­lars in fines un­less he re­plants trees.

Tony Lee: Big brother.

Larry Schuler: ONE more rea­son why I WILL NEVER LIVE IN WEST LAKE.

Lau­rie Pruser-Stock­man: Be­cause ju­nipers/cedars don’t re­gen­er­ate and grow wild ... STUPID STUPID STUPID ... I won­der ... is this gov­ern­ing body left or right lean­ings?

James Davis: What if it’s only a bush? Or a mere shrub­bery? And does said or­di­nance ap­ply ex­clu­sively to the veg­etable king­dom, or

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