New reports today are that the American Cancer Society is rethinking its position on advocating for aggressive screening of breast and prostate cancers. The lack of evidence of the benefits of screening has been around for a while (just ask UNC’s Dr. Nortin Hadler). But Hadler’s campaign is drawing other researchers and finally bearing fruit:
Both [the PSA test and mammograms] have a problem that runs counter to everything people have been told about cancer: They are finding cancers that do not need to be found because they would never spread and kill or even be noticed if left alone. That has led to a huge increase in cancer diagnoses because, without screening, those innocuous cancers would go undetected.
At the same time, both screening tests are not making much of a dent in the number of cancers that are deadly. That may be because many lethal breast cancers grow so fast they spring up between mammograms. And the deadly prostate ones have already spread at the time of cancer screening. The dilemma for breast and prostate screening is that it is not usually clear which tumors need aggressive treatment and which can be left alone.
This goes right to the heart of what is wrong with our health care system. Costs are skyrocketing, in part because of all these screening tests. Add in aggressive treatment for conditions that don’t need treatment – like, apparently, many “innocuous cancers,” and you are really wasting money. That’s not the worst of the problem however. This overtreatment means that our medical system often delivers what North Hadler calls “type II medical malpractice” or excellent care delivered very well that is completely unnecessary and ineffective.
Even excellent care can have serious side effects. Think about the estimated 20% of men who undergo treatment for prostate cancer who end up either incontinent, impotent, or have other serious side effects. And this is for excellent treatment delivered well. The catch? Many didn’t need the treatment in the first place.
This is going to be one of the most wrenching changes in our crazy health care system. We believe we should get every test, every treatment no matter what. But this really isn’t solely or even primarily a matter of cost. Overtesting and overtreatment means delivery of care that is ineffective and harmful. The current reform bills move us towards addressing these issues with money for research on the comparative effectiveness of treatments, drugs, and other procedures. But changing people’s attitudes about how they and their families get health care will be the real challenge.