Overdiagnosis and overtreatment

For the individual patient and doctor, one cultural model is “find cancer and cut it out.” That seems the compassionate thing to do; cancer is, after all, quite scary. Even scarier is the following quote attributed to Dr. Otis Webb Brawley, now the chief medical officer for the American Cancer Society:

We at Emory have figured out that if we screen 1,000 men at the North Lake Mall this coming Saturday, we could bill Medicare and insurance companies for $4.9 million in health care costs [for biopsies, tests, prostatectomies, etc.]. But the real money comes later – from the medical care the wife will get in the next three years because Emory cares about her man, and from the money we get when he comes to Emory’s emergency room when he gets chest pain because we screened him three years ago.

… We don’t screen anymore at Emory, once I became head of Cancer Control. It bothered me, though, that my P.R. and money people could tell me how much money we would make off screening, but nobody could tell me if we could save one life. As a matter of fact, we could have estimated how many men we would render impotent … but we didn’t. It’s a huge ethical issue.

(Brawley and Goldberg 2011) Screening for prostate cancer with PSA has a legacy that will not go away. The following comments are by the primary care doctor epidemiologist that works with Dr. Jeffries:

Well in our study we sent out, we had 380 surveys on prostate cancer treatment decision-making. Over half of patients chose surgery and 80 percent of them did robotic surgery. They were convinced that there are fewer side effects with robotic. And if you read the marketing materials for robotics, it’s pretty much marketed that way. It doesn’t say we have less side effects this way, but it’s the most innovative and technologically advanced in order to minimize your side effects from the surgery. But do you know how much one of those machines cost?

173We looked it up. And we were talking to Dr. Jeffries about that, and he was like, “yeah it takes a good five years of everyday use to pay one of those machines off.” And yes, there is pressure that comes down from the hospital when they put out that kind of money, they want to see their machine used so they’ll do all the marketing for you but they still want to see it used. So when you’re, imagine you’re in the office with the patient who says, “I have this cancer get it out of me.” It has to be awfully tempting to say, “Oh, we can do that for you.” Rather than, “Well, and you know it’s sort of a low risk cancer. One of the options and I would recommend this one would be let’s watch it for a while. Not that we won’t eventually do surgery or we may not have to. There is …”

Overtreatment is one part of the healthcare crisis. Another part is overdiagnosis (Carter et al. 2015). Doctors act in the setting of the body politic, and in many ways, the conflict of societal values gets played out in what I consider to be the poster child, the first and most controversial case of overdiagnosis: PSA screening. There are astute clinicians that have already given the clarion call that prostate cancer is the tip of the iceberg; pulmonary embolism is currently being debated in the medical literature as an example of overuse in emergency department settings (Brownlee 2007; Welch et al. 2011). Shannon Brownlee also gives the following description at Johns Hopkins:

The cancer center, by contrast, lures a better-insured clientele, in part because the disease itself is most common among Medicare recipients. Chemotherapy represents a major source of profit for any cancer center, because the hospital buys the drugs wholesale and permitted by Medicare and the state of Maryland to mark up the price by about 16 percent. Radiation therapy is also profitable. “There’s an incentive to say we’re not going to do psychiatry because we lose money,” said Langbaum. “So we really should refuse to admit psychiatry patients and admit more surgery patients. The problem with that is this is a teaching institution, and we can’t pick up and choose what we will take care of. So we try and develop programs that do make money to [be able to] run the programs that don’t make money.”

In other words, Hopkins does what all hospitals must do: It uses the profits it makes on some patients to cross-subsidize the care of others. A hospital’s “refuges of profit,” as departments that make money are sometimes called.

(Brownlee 2007: 81–82) Throughout my entire medical career, I have been warned of the “demographic imperative,” referring to aging baby boomers who will consume ever-larger segments of society’s healthcare resources as they accumulate 174chronic diseases and die. Dr. Spangler referred to the demographic imperative when one of the medical assistants told her one of the patients was requesting a handicap-parking sticker, which required a doctor’s signature. Dr. Spangler looked at me and said, “It’s not gonna help because all the handicap parking spots are going to be taken. He won’t be able get a handicap spot because everybody’s getting older.”