Home > Dr. Ward's Newspaper Column Home > 2010
To scan or not to scan
February 01, 2010It might have been predicted that as health care reform began its way through a legislative process that is often compared with a sausage grinder, something in the lofty and distinct goals of simultaneously providing health care coverage for all Americans and reigning in health care costs would have to give. What has given the most is the goal of reigning in health care costs.
In that context, I followed last year's media-hyped and anxiety-laden controversies about the use of mammography and CT scanning with interest. At first glance they would seem to be issues that orbit the health care reform solar system at its fringes, but in reality, they are both important and instructive about what lies ahead, dead center.
In July, a study from Europe made the claim that one in three breast cancers detected by mammography was over-diagnosed and overtreated. They further claimed that for every woman who will avoid dying from breast cancer because of mammography, 10 will be told they have breast cancer earlier than otherwise without a change in outcome, 100 women will have at least one false alarm and half of those will have a negative biopsy.
Then on Nov. 17, the US Preventative Services Task Force, a quasi-governmental volunteer panel populated of primary care physicians and epidemiologists, published new guidelines. In contrast to those of the American Cancer Society and the American College of Radiology, the age that women should start routine mammograms went from 40 to 50, the frequency from every year to every other year, and they further recommended that routine screening stop altogether at age 74. They did not deny that early and late mammograms save lives but claimed that they did not save enough lives to warrant the current intensity of screening.
This has prompted a firestorm of back and forth opinion and debate. Imaging experts accused the task force of bias in the studies they chose to use in their analysis, underestimating the benefits of mammography and overestimating harm. And it was suggested that they had been influenced by a political mandate to decrease screening costs. And cancer survivors diagnosed by mammograms performed between the ages of 40 and 50 came unglued at the idea that they might have been written off as not worth saving. The heat generated by these proposed guidelines led Kathleen Sebelius, President Obama's Secretary of Health, to tell women and Medicare to ignore the Task Force and follow the American Cancer Society guidelines instead.
This furor was in full swing when, on Nov. 30, a study was widely reported that 35 percent of CT scans performed in the U.S., and 52 percent of patients getting them, were unnecessary. Further, 78 percent of the unnecessary scans were delayed-phase imaging scans that, though they give more detailed pictures, also include greater exposure to radiation. The authors estimated that this degree of excessive CT imaging, a fairly recent phenomenon, could eventually result in 23,000 radiation-induced cancers per year. On its heels came another report that demonstrated widely varying amounts of radiation dose for the same study, dependent on protocol and equipment. A survey of four hospitals and over a thousand patients found up to 13 times as much radiation for some patients compared to others.
This time, however, the response was muted. There is disagreement about the degree of harm from medical radiation. The estimates of risk were extrapolated from radiation exposures in Hiroshima, Nagasaki and Chernobyl; not exactly the same as X-rays and CT scans. And experts expressed concern that patients who really needed CT scans might refuse them. It was noted that even in babies, where the risk of a chest CT causing an eventual cancer is as high as 1 in 200, CT scans save thousands of infant lives every year. Blame was cast on the availability and speed of modern CT scanners, profit motives and physician fears of getting sued, but no one challenged the claims of overutilization of imaging studies, the overexposure to radiation, or the potential for harm with the same fervor as the mammography guideline changes.
Eventually, a different Congress will have to address health care costs. When they do, these two examples may prove case in point. We can cut costs, but we have no reason to sacrifice lives to do so. If, as in mammograms, imaging saves lives, we should be willing and able to save them. But when our current medical system put lives at risk, as in CT imaging, be it in the name of convenience, profit or liability, we should change the incentives and save lives — and in the process decrease costs. In the meantime, the only recourse for patients is to ask their doctors and listen to what they say before they consent.
Dr. Ward is a medical oncologist at Puget Sound Cancer Centers. He can be reached at (425) 775-1677.