USA TODAY International Edition
Cancer patients, doctors fret about overtreatment
Unnecessary scans, therapies eat up money, time — and they might even worsen outlook
When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.
“You’re terrified out of your mind” after a diagnosis of cancer, said Dennison, 55, from Orange County, Calif.
In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy regimen, she said, because she had no idea there was another option.
Medical research published in The New England Journal of Medicine in 2010 — six years before her diagnosis — showed that a condensed, three-week radiation course works just as well. A year later, the American Society for Radiation Oncology, which writes medical guidelines, endorsed the shorter course.
In 2013, the society went further and specifically told doctors not to begin radiation on women like Dennison — who was over 50, with a small cancer that hadn’t spread — without considering the shorter therapy.
“It’s disturbing to think that I might have been overtreated,” Dennison said.
Dennison’s oncologist, David Khan of El Segundo, Calif., said he was worried that the shorter course of radiation would increase the risk of side effects, given that Dennison had undergone chemotherapy. The latest guidelines, issued in 2011, don’t include patients who’ve had chemo.
Yet many patients still aren’t told about their choices.
An analysis for Kaiser Health News found that only 48% of eligible breast cancer patients today get the shorter regimen, in spite of the additional costs and inconvenience of the longer type.
The data “reflect how hard it is to change practice,” said Justin Bekelman, associate professor of radiation oncology at the University of Pennsylvania Perelman School of Medicine.
A growing number of patients and doctors are concerned about overtreatment, which is rampant across the health care system, said Martin Makary, a professor of surgery and health policy at the Johns Hopkins University School of Medicine in Baltimore. Doctors estimate 21% of medical care is unnecessary, according to a survey Makary published in September in Plos One.
Unnecessary medical services cost the health care system at least $210 billion a year, according to a 2009 report by the National Academy of Medicine, a science advisory group.
Those procedures aren’t just expensive. Some harm patients.
Overzealous screening for cancers of the thyroid, prostate, breast and skin leads many older people to undergo treatments that are unlikely to extend their lives but can cause needless pain and suffering, said Lisa Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice.
“It’s just bad care,” said Rebecca Smith-Bindman, a professor at the University of California, San Francisco, whose research has highlighted the risk of radiation from unnecessary CT scans and other imaging.
All eligible breast cancer patients should be offered a shorter course of radiation, said Benjamin Smith, an associate professor of radiation oncology at the University of Texas MD Anderson Cancer Center.
Smith, who is updating the expert guidelines, said there’s no evidence that women who’ve had chemo have more side effects if they undergo the condensed radiation course.
Shorter courses save money, too. Bekelman’s 2014 study in JAMA, the journal of the American Medical Association, found that women given the longer regimen faced nearly $2,900 more in medical costs in the year after diagnosis.
The high rate of overtreatment in breast cancer is “shocking and appalling and unacceptable,” said Karuna Jaggar, executive director of Breast Cancer Action, a San Francisco-based advocacy group. “It’s an example of how our profit-driven health system puts financial interests above women’s health and well-being.”
Just getting to the hospital for treatment imposes a burden on many women, Jaggar said. Rural breast cancer patients are more likely than urban women to choose a mastectomy, which typically doesn’t require radiation.
Meg Reeves, 60, believes much of her treatment for early breast cancer in 2009 was unnecessary. She feels as if she was treated “with a sledgehammer.”
Reeves lived in a small town in Wisconsin and had to travel 30 miles each way for radiation therapy. After she completed treatment, doctors monitored her for eight years with a battery of annual blood tests and MRIs.
Yet cancer specialists have repeatedly rejected these kinds of expensive blood tests and advanced imaging since 1997.
Beyond wasted time and worry, these scans expose women to unnecessary radiation, a known carcinogen, said Gary Lyman, a breast cancer oncologist and health economist at the Fred Hutchinson Cancer Research Center. A National Cancer Institute study estimated that 2% of all cancers in the U.S. could be caused by medical imaging.
Kathi Kolb, 63, was staring at 35 radiation treatments over seven weeks in 2008 for her early breast cancer. But she was determined to find another option.
“I had bills to pay, no trust fund, no partner with a big salary,” said Kolb, from South Kingstown, R.I. “I needed to get back to work as soon as I could.”
Kolb asked her doctor about a 2008 Canadian study showing that three weeks of radiation was safe. He agreed to try it.
Even the short course left her with painful skin burns, swelling, respiratory infections and fatigue. But she fears these symptoms could’ve been twice as bad.
“I saved myself another month of torture and being out of work,” Kolb said. “By the time I started to feel the effects ... I was almost done.”