Cancerous Beliefs On Screening

January 13, 2016 / Rocky D. Bilhartz / 10 Comments

Cancer screening has NEVER been shown to save lives.

That’s the eye-catching title of a recent article emanating from Academic medicine.

I liked it.

I’ve known for some time that we bother too many patients with absolutely no symptoms of disease under the guise of Evidence Based Medicine (EBM). So, of course, I started reading it.

The lead author has been involved with other discombobulating publications of statistical mumbo-jumbo. So, naturally, I wondered what sensible and non-sensible use of statistics I’d encounter.

It didn’t take long for me to find both.

The article opens with an infographic summarizing the presumed benefits (based upon one study) of screening for colon cancer with a simple, non-invasive, test that looks for hidden blood in your stool. We call it fecal occult blood testing (FOBT).

Now, don’t get too caught up in all the text below. Just look at all the little people on the right side of the infographic:

One caption next to the little people reads “Deaths from colon cancer.” The other reads “Overall mortality,” which means any death from any cause.

And, yes, here’s what it wants you to know:

Screening for colon cancer reduces deaths from colon cancer. But, you will still die. Regardless. From one thing or another.

I’ll say it again.

Screening people (with FOBT) for colon cancer may reduce their chances of leaving life because of colon cancer. But, they will still leave life due to something, at a statistically similar rate, whether they’re screened or not.

Basically, the article’s authors want you to believe that while screening reduces some deaths, it must (in some way) cause others. But, really, the fundamental principle at work here isn’t too hard to follow. I’ll break it down for you.

In fact, here’s what was done in the original study from which the infographic was derived:

1) Take a bunch of people who are, on average, about 62 years old.

2) Screen some with a test. Don’t screen others.

3) Screen some people once a year for eleven years. Screen others twice a year for 6 years. Collectively, call them the screening group. The non-screened people will be the control group.

4) Now, let time pass.

5) Now, let even more time pass.

6) Keep track of no additional tests, screening studies, colorectal procedures, or other medical stuff that gets done to anybody after a handful of screening years are complete.

7) Then, check back in 30 years.

What will you find?

That most people are dead by then. No matter what was done. Just less people in the screening group died specifically from colon cancer.

So, case closed.

Screening NEVER has been shown to save lives.

* * *

The authors go on to mention a few other statistical compilations in their quest to prove the point already made by their infographic. And, their assumptions just may be true. But, I challenge you to read the original articles from which they make their conclusions.

For example, take the use of mammography for breast cancer screening. Eleven individual trials were mentioned in the article they referenced. All but one trial found a numerical decrease in breast cancer deaths with screening mammography. Two of the trials even showed statistically significant reductions in all-cause death.

How many of the trials showed statistically “proven” harm and increased all-cause death with screening mammography? None.

Here’s another example.

Take the use of ultrasound to screen for an aneurysm in your belly (something called an abdominal aortic aneurysm). The same article they cite analyzed the results of four clinical trials. All four showed numerically fewer deaths from aneurysm rupture in those getting an ultrasound procedure. All of them also showed numerically fewer all-cause deaths in the group getting screened.

You see why your angle matters when you report the evidence?

It always matters.

In fact, the analysis (specifically called a meta-analysis) used for this paper’s conclusion about aneurysm screening was selected because it had the longest follow up. That’s right. Kind of like the infographic above. Pick anything tracking life long enough, and things will always tend to converge toward the inevitable… death. Interestingly, despite this fact, the meta-analysis still revealed a 45% relative risk reduction in aneurysm-related death and a 2% relative risk reduction in all-cause death in those who were screened.

Again, your angle always matters.

And, trust me. There’s plenty of controversy related to screening procedures. But, don’t let anyone fool you. Most of it relates to cost effectiveness.

And, yes, since healthcare exists within an outrageous stratosphere of costs inflated by third-party payment (including our government’s), people quoting costs are rarely certain what they are even quoting.

Pricing is so far disconnected now from individual value that everything is really just like cancer screening–one discombobulated web of confusion.

You see, the authors of the infographic article go to great lengths to make it crystal clear to you that performing a chest X-ray, to screen for lung cancer, won’t save lives.

But, rather ironically, this so-called evidence-based fact of population medicine doesn’t disprove the subjective truth that ordering a chest X-ray on Bob, in my office today, is the right thing to do. It doesn’t help reconcile the fact, that this strategy–for reasons that don’t find their way into a statistical equation–provides “value” to Bob, today.

How do I know?

Because, I know Bob.

And, frankly… you don’t.

* * *

Think about it this way.

You were taking Medicine X, but it had too many side effects for you. I changed it to Medicine Y. Now, you are doing fantastic, but it’s January 1st of a new year.

Your same health insurance company has made some modifications to your prescription plan. They will no longer pay for Medicine Y.

Why?

Well, they claim the “evidence” says the side effects for Medicine X and Medicine Y are the same.

“Are they the ones taking it?” you ask. Because, you already know such evidence is nonsense. At least for you. You are the one getting the side effects.

But, the reality is that you have no say. And, ultimately, neither do I as your doctor.

You see, that’s basically the way of central authority healthcare. Whether the government runs it or not, that’s a single-payer system. And, yes, that’s nonsense.

* * *

Almost amusingly, the infographic’s angle toward cancer screening is ultimately similar to mine. I will likely choose to do less, rather than more. Most doctors do. But, whatever I decide, it will inevitably be based upon varying degrees of both sensible and non-sensible statistical understanding.

So, I’m not telling you to get a mammogram. I’m not telling you for which cancer you should be screened. Most of those things aren’t my area of expertise, anyway.

But, I’m telling you to find a good doctor. And then, support a system that allows for him or her to treat you as an individual, instead of toward the mean.

You see, we need clinical trials. We need intelligent lead authors combing through their data. But, not for the purpose of proving less is more. Not for the purpose of determining what boxes should get checked inside an electronic medical record.

We need these things, ultimately, just for Bob.

And, obviously, spending billions of government dollars to develop complicated physician payment schemes, built around ordering certain screening tests that may or may not even be helpful, is not the answer.

Having the Health Department issue actual grades to physicians based (in part) upon their participation level and performance on certain screening measures, is a philosophical error that ultimately penalizes the individual patient more than anybody.

You see, the nuances of medicine will never be mastered by regulatory onslaught.

Actually, this is what is killing us.

Not screening procedures.

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Clinical Trials

Cathleen Wentz

I love that line, “… the nuances of medicine will never be mastered by regulatory onslaught.” I have been thinking about changing my PCP for a number of reasons that I won’t go into. However, he seems to have been infected with the “population health” bug for the last few years, and I feel less and less like an individual when he talks to me.
- Rocky D. Bilhartz
  
  Thanks for your comments, Cathleen.
Jawaralal_Schwartz

Yes, I surely agree that the “nuances of medicine will never be mastered by regulatory onslaught.” Lots of regulators and other politicians need to learn that. But we also must recognize that many healthcare practitioners, including more than a small fraction of physicians, deliver old-fashioned, under-thought, or downright invalid and fallacious or just plain lazy diagnostics and treatments. Those people are a large fraction of those who bill, and they need regulation because professional bodies and state licensing and medicare hardly scratch the surface of the sea of charlatans and incompetents who claim to be helping us. More power to “good” doctors like you, Dr. Rocky. The challenge for us, the great unwashed, is to find you in the sea of information, a lot of it misleading and bogus or unavailable. Free market forces by themselves will never make much of a dent in the ocean of underperforming providers. Indeed, these forces may end to protect them when geography and highly effective paid lobbying is harnessed in their behalf.
- Rocky D. Bilhartz
  
  Thanks for the kind words.
  
  I also understand your perspective regarding the need for regulations on those “sea of charlatans.” I understand this perspective well. Mainly, because it used to be my own.
  
  Likewise, my goal is not to convince you (or someone else) to change your perspective. I only seek to pass on the information and knowledge I came across that changed mine.
  
  I’ve written about many of these points already, so I don’t feel the need to rehash all of it. But, this point is so critical to grasp: Marginal care would vanish in a market where few would be willing to pay for it.
  
  Although I would have classified absolutely none of my Pre-Med classmates at Rice University as being “lazy,” those individuals “under-performing” in medicine today continue to do so predominantly because a third-party is paying for them.
  
  For example, take something “health” related that people are paying for themselves. I’m not the expert here. But, pick some alternative or complimentary medical therapy. Say, intravenous Ozone therapy. There is some science there, but definitely no third-party reimbursement for it.
  
  I understand there’s a place in New York that has done 175,000 treatments over the last three decades treating patients for numerous medical ailments. You think the therapy is sham? Maybe. But, you’ll never prove that to the people who have found and continue to seek “value” from it.
  
  Ultimately, if it is a sham, people will figure that out. With or without the government. Someone will expose it. Someone will produce a superior product that will help the people seeking those services even more. People don’t willingly trade their own dollars for subpar stuff for very long. Now, when it’s someone else’s dollar? That probability greatly escalates.
  
  Stating that “free market forces by themselves will never make a dent” in subpar performance is really like saying you would never be able to tell the difference between the Ritz-Carlton and a Motel-6 in the absence of government regulations.
  
  Trust me, in a free market, where you directly paid for what you received, Motel-6 would only be able to masquerade as the Ritz-Carlton for a short time. And, If I were a Motel-6, you’d know. Then, you wouldn’t have to waste your time reading my blog. 🙂
  
  Thanks for all your comments.
  
  Kind regards,
  RB
- ASSUME THE PHYSICIAN, by John
  
  Reliance on the worst sort of people (politicians and bureaucrats) to regulate some of the best sort of people (physicians) makes no sense to me at all.
ASSUME THE PHYSICIAN, by John

Fantastic article. Excellent.. Thank you
sanram

Dr. Bilhartz,

1. How does third-party payment inflate costs?
2. What sort of cost effectiveness-related controversies surround screening procedures?
3. You said that clinical trials are important, but mentioned that they should be done because of Bob. Can you talk more about that?

Thanks,

Santiago
- Rocky D. Bilhartz
  
  1. I hesitate saying “always,” but adding middlemen to economic exchanges will “always” increase costs. The more parties who seek to add their stake in the interaction between physician and patient, the more pricey things become.
  
  Over the last 100 years, third parties in medicine have been involved in all the following which have driven price increases: increased licensing laws (leading to acute physician shortages and healthcare access inequalities), private insurance creation (leading to moral hazard–concept that you will seek more care when it is “paid for” by many others or when your deductible is met), government insurance creation (a.k.a. Medicare, again more moral hazard as elderly are more prone to utilize medical resources), and massive third-party legislation (focused on price-fixing, something that historically has never controlled costs, and leading to added bureaucratic costs).
  
  For more details, you would enjoy the readable two part series on the economic history of American Healthcare here:
  
  http://alertandoriented.com/an-economic-history-of-the-american-health-care-system-part-1/
  
  2. When we speak of screening procedures, we really speak about “population medicine.” If the procedure works to eliminate a cancer, great. But, if the procedure costs $1Million per person to do it, the entire population can’t be screened, no matter how successful the procedure may be.
  
  3. We seek data from trials to obviously help patients. But, we must not forget that our real focus (at least for me) is to help the individual patient sitting in front of me on that day (a.k.a. Bob). If we lose sight of Bob, we have lost our focus. For example, if the “population” as a whole benefits from better blood pressure control in a clinical trial, we often conclude that we must give Bob blood pressure medicines galore until his blood pressure gets to what we found to be best in the trial.
  
  This may or may not be the best thing for Bob. Maybe, Bob has a dozen medical problems, of which blood pressure is just one of them. Maybe, he will die of colon cancer instead, so our focus should be more in that area than in blood pressure. This requires “judgment” with Bob’s interest, not some population of people, at heart.
Rocky D. Bilhartz

I comment about this concept more in my book. I’ll share with you two basic themes:

1) I did not journey through my lengthy medical training alongside a “sea of charlatans.” That has not been my perspective at all, but rather, quite the opposite. I do not dispute the existence of “bad apples” in any bunch, but by and large, the physicians I’ve come in contact with during my career are doing the best they can in a challenging (and often hostile to them) healthcare environment.

When viewed from my experienced perspective, one sees the “sea of charlatans” as more perception than reality. Perception, of course, is driven by many things (experience, social interactions, media, etc…). And, most of these things only reflect partial truths.

Ultimately, it is our own perception of “value” that helps establish whether we see someone as being a charlatan or not. And, most people now find less “value” in the healthcare system within which they interact. Thus, there must be charlatans. Which leads me to the second theme…

2) When a true charlatan does exist, it’s only reasonable to investigate how this person is being allowed to exist in the current system, and what could be done to best rid the system of these types of people?

One common method in a highly regulated system is to impose more regulations. This will fix things. When it doesn’t, we recommend imposing more regulations, and so forth. When something doesn’t work, we just think it was underfunded. So, we dump more resources into it. Almost never do we stop to think that the problem may have been the regulations themselves. The answer may actually be to unwind, and remove some of the regulated incentives that others are using to gain an unfair advantage.

One of the more regulated systems I have had the opportunity to work within (the VA Healthcare System, which is mentioned in my book), ironically has had some of the most telling stories of healthcare corruption in recent times.

Ultimately, accountability can be achieved in a number of ways. And, the easiest way, may actually be through the mutual gift of free exchange.

From Jeffrey Tucker: “At some point today, you will undoubtedly engage in some economic exchange. Use the opportunity to reflect on what a glorious dynamic underlies it. You can say, ‘thank you.’ The person who takes your money can say, ‘thank you.’ Such opportunities account for most of the peace and prosperity we enjoy this side of heaven.”

In the system alluded to by Tucker, regulating the “sea of charlatans” suddenly becomes less complex.
DrRajHealth

Agree that personalized shared decision-making between a patient and her conscientious physician is the best model. I also agree that most physicians practice conscientiously. However, some do not–roughly 20% by Pareto principle.

Nearly all of the regulatory burdens suffered by the 80% of conscientious doctors like yourself is directed towards the 20% who sully our profession. The challenge isn’t managing good doctors. The challenge is managing the poor ones. The good doctors suffer a bystander effect.

You stated, “I will likely choose to do less, rather than more. Most doctors do.” Yes, you and about 80% of good docs out there. But, 20% may not. I have a colleague who has a similar practice size as mine and who does about 4-6 computer navigational bronchoscopies per week in order to biopsy lung nodules found by a new lung cancer screening recommendation (low dose CT screening for lung cancer). I do, at most, may be 4 bronchoscopies per month for this purpose (75% less than my colleague). The fact is, about 70% of lung nodules spontaneously resolve or remain unchanged so conservative management with close clinical and radiographic surveillance will suffice for most patients and keep them out of harm’s way by our hands.

How we paint the picture to the patient matters.

I may say, “Yes, there’s a nodule, but, you know, most of these nodules just disappear/remain unchanged. You have no alarm symptoms. Based on your risk, I recommend we repeat the CT in one year.”

My colleague may say, “There’s a lung nodule. We can watch it, but you can never tell…I want you to have peace of mind. We can biopsy this thing and know today.”

Moreover, I’m not certain we as a health system are truly good at limiting utilization. Consider a community with one CT scanner. Then, one day a second CT-scanner is introduced at a competitor down the road. One would assume the volume of CT scans performed would be about 1/2 of total at each location. But, in short time the volume of CT scans in the community actually doubles. If there’s a 3rd CT scanner introduced, the volume of scans performed triples.

Volume increases to fill capacity.

I do agree there is a crisis in scientific research today. There are more retractions then ever. There are more original studies than ever which cannot be replicated. For an informative and humorous perspective, listen to https://soundcloud.com/science-vs-season-1/science

Cancerous Beliefs On Screening

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