NYT Kristof's A Possibly Fatal Mistake Shows Future of Health Care. It Isn't Good.

NY Times columnist Nicholas D. Kristof wrote a heartfelt piece "A Possibly Fatal Mistake" about his college roommate Scott Androes, who recently was diagnosed with metastatic prostate cancer. His story illustrates the problem with the current health care system.  It isn't about the lack of health insurance. It's about the obstacles all patients face in making the right decisions and the right treatment.

Something that will increasingly be harder with consumer driven health care.

Kristof lets his 52 year old friend, who is well-educated (graduate of Harvard, financial and pension consultant) and also was uninsured starting in December 2003, tell the story.

In 2011 I began having greater difficulty peeing. I didn’t go see the doctor because that would have been several hundred dollars out of pocket — just enough disincentive to get me to make a bad decision.

 

Early this year, I began seeing blood in my urine, and then I got scared. I Googled “blood in urine” and turned up several possible explanations. I remember sitting at my computer and thinking, “Well, I can afford the cost of an infection, but cancer would probably bust my bank and take everything in my I.R.A. So I’m just going to bet on this being an infection.”

 

I was extremely busy at work since it was peak tax season, so I figured I’d go after April 15. Then I developed a 102-degree fever and went to one of those urgent care clinics in a strip mall. (I didn’t have a regular physician and hadn’t been getting annual physicals.)

 

The doctor there gave me a diagnosis of prostate infection and prescribed antibiotics. 

Androes, after being diagnosed with metastatic prostate cancer, like most of us, would reflect on what went wrong.

I read Nassim Taleb’s book “The Black Swan” and imbibed his idea that you should keep an eye out for low-probability events that have potentially big consequences, both positive and negative. You insure against the potentially negative ones, like prostate cancer.

So why didn’t I get physicals? Why didn’t I get P.S.A. tests? Why didn’t I get examined when I started having trouble urinating? Partly because of the traditional male delinquency about seeing doctors. I had no regular family doctor; typical bachelor guy behavior.

I had plenty of warning signs, and that’s why I feel like a damned fool. I would give anything to have gone to a doctor in, say, October 2011. It fills me with regret. 

What can we learn about his experience and the future of our health care system?

Smart educated patients can make bad decisions

Androes is highly educated. If anyone should understand the cost benefit analysis of money and health, it should be a pension consultant educated at Harvard. He had opportunities to seek care sooner, but chose not to. Understanding this psychology is important as it is the underpinning of consumer driven health care - patients will choose more rationally if they have more financial skin in the game. Yet all I continue to see is evidence to the contrary.

First, Androes had many obstacles and not all related to lack of health insurance. He didn't choose to see a doctor when symptoms started in October 2011 because the cost didn't seem worth it. This is where our common sense and experience falls short. We've all had experiences of an ache, pain, or symptom. Many go away on their own. Androes like many other patients have this "success" and filed it away. Plus, work is too busy or important to put on hold (another major problem with the economic crisis of 2008) and personal health takes a back seat. The problem is our previous success with other symptoms may not necessarily apply to the current symptom.

It isn't clear if at that point he researched his symptoms with the always available Dr. Google. Unfortunately, like many patients he winged it hoping for the best. Had he thought about it some more, he might have realized that he never had urinary complaints prior to this episode. Having urinary problems are quite uncommon in young or middle-aged men.

So, Androes, like many others, he extrapolated his prior experience to his current situation, which may not have been appropriate.

Who has time to be sick? Don't "bet" on the wrong diagnosis with Dr. Google

Second, when he did have blood in the urine, Androes did consult Dr. Google. Dutifully, Dr. Google pulled up two possibilities. Infection or prostate cancer. Androes "bet" that it was infection. This is no different than "winging" it. Unlike the first episode of urinary problems, Androes clearly is informed about the possibility of cancer. Problem is he can't afford a catastrophic illness like cancer either from a financial or time point of view.

Here is the reality. None of us can afford it. There is never a good time to be diagnosed with cancer or any other serious life-altering illness. Yet is behavior is common among many patients I see. Their job or their financial assets are more important than their health. Androes "chose" to go after April 15th, after tax season, when it was most convenient for him. Dr. Oz nearly made a similarly bad decision regarding his colonoscopy and colon cancer screening a few years ago and then again when he failed to follow-up as recommended for colon cancer surveillance. Part of the reason we all fall into this cognitive trap is that for the most part, our body does a good job in running despite what we eat, our sedentary lifestyle, and long hours of work.
 
The most important financial asset is your health. With good health you can always make more money, with more money you can't buy good health.  So certainly, Androes had his less than optimal choices.

Did doctors miss a chance to diagnose prostate cancer earlier?

What about the health care system and doctors? Did we miss an opportunity?

Yes. It is possible there were two, though unclear if it would have made a difference in his case.

When Androes sought care with a doctor in urgent care and a urologist, he noted the former diagnosed him with a prostate infection and the latter did blood work. It isn't clear whether either doctor did a rectal exam to feel the prostate. A patient with metastatic prostate cancer with a PSA of 1,110 (normal range less than 4) should have a very abnormal prostate exam.

Had a prostate exam been done, either doctor had a very good chance in telling him he had prostate cancer prior to any confirmatory blood work. At that point, however, even with this knowledge it would have been too little and too late to alter the outcome or overall prognosis.

The second issue is whether the benefits of physical examinations or lab testing, like PSA, would have made a difference. Neither have been demonstrated to save lives. In other words, as a nation we might feel better that everyone gets an annual check-up or lab testing, but there is no scientific evidence that either help. Also, as noted previously, it isn't clear patients will seek preventive care for the reasons above.

So, how does this one story, which sadly is repeated too often by different writers and involves different protagonists, predict our health care future?

It does in the following ways:

Common sense does NOT apply to health care- four challenges in making good decisions about health

Common sense does not apply to health care. Patients may have symptoms they have never had before and erroneously assume based on prior experience, that this new problem is nothing to worry about. Denial is a powerful emotion and can cause inaction precisely when action is needed.

Second, when patients feel fine they don't protect against low probability but high risk problems. Will people buy health insurance? Will they demand for preventive screening tests that save lives? Will they willingly get vaccinated against preventive illnesses? Increasingly we see more parents choosing not to have their children immunized and then nationally see many preventive illness, like pertussis, return again with significant consequences.

Third, there are many obstacles preventing good decision making. Whether higher deductibles, copays, or simply working too hard to focus on one's health, people ignore their health until they have no choice or have symptoms. If Androes who had the good fortune of being educated at an elite Ivy League school made poor medical decisions, what are the implications for the rest of society? Patients should be more motivated to take charge of their health, yet it is likely the drive to consumer driven health care will make the nation's overall health care worse, not better. A similar experiment was attempted in retirement planning with devastating outcomes for retirees.

Fourth, people are increasingly devaluing the important of expertise and experience with the increasingly ease and availability of information on the internet. That isn't to say that non-experts cannot make a contribution to furthering progress. The challenge is that the availability of data provides many non-experts a false sense of certainty and absolute truth which is not necessarily true in medicine. We do have genomics, but it is in its infancy. We do have personalized testing, but it isn't clear if knowing the results will be medically important.  When dealing with the complexity of the human body, nuance and ambiguity are prevalent.

More patients are emailing me requesting for CT scans or MRIs because the office visit copay is too expensive. They don't feel that seeing a doctor, taking a detailed history or examination is worth it.

Yet, to counter the issues above it is doctors who can convince people to act in getting testing, treatments, and interventions when they don't want to emotionally or are uncertain what to do. It is doctors who can encourage patients to get preventive testing and immunizations when faced with the overwhelming amount of information and clutter from the media, the internet, and friends. It is doctors who can tell patients when they must seek care and when they can safely skip. There is medical science and then there is everything else.

However, this is not where our country is headed. Too many believe that to lower costs and improve health outcomes, patients must make better decisions. Patients will do so if they have more financial responsibility and more cost transparency.

Show me the evidence because I don't see it.
What I do see, unfortunately, is more cases like Scott Androes.

The Best Health Insurance - Can Save Your Life

The Sacramento Bee recently ran the following opinion piece below.  A couple of additional comments not published follow.  Enjoy. 

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It’s that time of year when most of us pick a health insurance plan based simply on cost. It’s a belief that is often perpetuated by friends, family, and advice dispensed by many articles in magazines and newspapers. As a practicing primary care doctor, I can tell you that the advice is frankly wrong.

Health insurance isn’t a commodity like auto insurance. It’s not just about the price. They aren’t all equally good at keeping you healthy and well. The recent annual report by the National Committee of Quality Assurance, which has been evaluating health plans for twenty years, continues to report tangible differences among health insurance plans across the country as well as in California.

In a ranking of 227 HMO plans nationwide in important areas like immunization rates for children, appropriate use of antibiotics, blood pressure and cholesterol control, cancer screening in adults for breast cancer, cervical cancer, and colon cancer, only two of nine California HMO health insurance plans ranked in the top 15 percent. The remaining seven were in the bottom half. If all health plans across the country performed at the level of the top 10 percent, 186,000 Americans would be alive today. They would have consistently and routinely received the preventive care and medical interventions that have proven to save lives.

Naturally, it is hard to believe that your choice of a health insurance plan might actually save your life. You often pick your insurance based not only on price, but also if your doctor is in the plan. As a patient, high quality care means your doctor sees you quickly when you are ill, he is always willing to listen and explain, and the fact that he actually knows you as an individual. As a result, he should know what to do to keep you healthy, even as research points to the contrary.

A recent study by the Journal of General Internal Medicine found that only 20 percent of doctors correctly screened patients for colon cancer, the second leading cause of cancer deaths. The doctors likely to do the right thing were younger, board-certified, and used electronic medical records. Those most likely to incorrectly screen or not screen at all were older, much like the fictional television doctor, Marcus Welby. He’s a doctor we would all feel comfortable with and we would trust to keep us well.

Who did better, a health plan or a doctor? The HMO health insurance plans in the top 10 percent of performance screened 72 percent of their enrollees appropriately for colon cancer, three and half times more than the doctors. The bottom 10 percent screened 47 percent of patients. The news for enrollees in the more popular PPO plans is more worrisome. Screening rates of these plans were only 54 and 39 percent respectively for the top and bottom 10 percent of plans.

It’s not obvious the reasons for this difference in performance among health plans or the difference between doctors and health plans. Do better health plans have systematic ways of keeping patients healthy or reminding doctors at the point of care? Is it that doctors who are better naturally gravitate to health plans that are focused on prevention? After all, the work of screening and providing the preventive interventions are done by doctors not by insurance companies.

As a practicing primary care doctor, I constantly balance the art of medicine, the bedside manner, and the science, the evidence based research. Before I joined with a high quality health insurance plan, I thought I was pretty good. The initial data showed otherwise. Over the past few years, I’m far better at keeping my patients healthy. With this insight I now know that given a choice, I would always start with health insurance quality first and then the doctors selection second. It doesn’t sound right. It doesn’t feel right. The science part of my medical degree says it is right.

The striking difference between health plan performance means that a choice most of us view as a simple formality or even an annoyance, picking a health insurance plan, is really a choice between getting the best care or not. A true choice between life and death. Intellectually this doesn’t make sense. Doctors take care of us. They are accountable to keeping us well, yet the data and research seems pretty compelling.

This year 186,000 Americans won’t have the opportunity to make the right choice because the health plan they had wasn’t high quality.

Will you make the same mistake this year?

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The two California HMO plans that were in the top 15 percent in the nation were Kaiser Permanente Northern California and Kaiser Permanente Southern California.  Each takes care of more patients than the entire top 10 HMOs combined.

Dr. Oz, Colon Cancer Screening, Colon Polyp, and Colonoscopy - What Can We Learn

I'm a big fan of Dr. Oz. What is there not to like about the guy?  He's incredibly smart, a graduate of my alma mater, the Wharton School, energetic, pretty good looking, and charismatic.  Though as a doctor I don't always agree with him, as I practicing primary care doctor I have great respect for his mission of getting all Americans healthier. (I wished he could have given me a testimonial for my book, though he sent a nice email wishing me luck. Perhaps my next book?). Though I have a busy day job, the season premier for his second season was one I could not miss. He turned fifty in June and had a colonoscopy in August to screen for colon cancer.  As a result he saved his own life.

Dr. Oz had a colon polyp.  The polyp which was removed was found at the distal sigmoid and identified as an adenomatous polyp.  These types of polyps have the potential to become cancerous over time.  Had it been left in the colon undetected, it could have become cancerous over a period of years.  Had he had delayed his colonoscopy until age 60 it could have developed into a full blown cancer.  Like most of us, Dr. Oz admitted that life is busy and we often delay important screening tests because we don't have time.  Fortunately, the polyp was removed and the likelihood of developing cancer from that growth is essentially zero.  Nevertheless to make sure, he will be repeating a colonoscopy again in a few months.

Understandably, Dr. Oz was shocked and humbled by the experience and the colonoscopy finding.  No one likes to be a patient, particularly cardiothoracic surgeons, who are often in complete control.  Like many patients and particularly even more doctors, he had a bit of arrogance going into the procedure because he works hard on staying healthy.  The colon cancer screening test was simply a thing to check off on his to do list.  A formality, but nothing that was taken seriously.

Instead, the procedure saved his life.  As a result, instead of leading in the second season with a ratings favorite of weight loss, the doctor in Dr. Oz did the right thing.  He aborted the original premier of weight loss originally scheduled because of the surprising colonoscopy findings and refocused the premier on the nitty gritty about hunting down the second leading cause of cancer deaths and filmed his most personal show ever.

He argues, rightly, that we must make time to do the right things.  Had he not been the host of his show, he would have been inclined to do procrastinate as he is a "sloppy patient"".  "Lifestyle is not the cure all by itself."  Part of being healthy and staying healthy is getting screened for cancer, high blood pressure, high cholesterol, and diabetes.

Dr. Oz had no symptoms, no family history of colon polyps or colon cancer.  What is particularly heart wrenching is that thirty-two thousand Americans died of colon cancer because they were never screened.  When caught early, colon cancer is highly curable.

According to Dr. Oz's expert, the majority of patients with colon polyps have no symptoms.  In other words, a deadly time bomb could develop and you wouldn't even know it unless you looked.  Even more disturbing is that seventy percent of patients with colon cancer have no family history.

Although Dr. Oz recommended that all Americans age 50 years and older be screened for colon cancer with a colonoscopy, his polyp was discovered at the distal sigmoid which would have been easily reached with a sigmoidoscopy.  Other options for colon cancer screening also include a virtual colonoscopy, stool testing, stool DNA testing, or barium enema, which are all recommended by the American Cancer Society.

My personal belief is out of all the options to screen for colon cancer, starting at age 50 all Americans who are otherwise healthy and have no family history of colon cancer or polyps should opt either for annual stool testing with a sigmoidscopy every five years or colonoscopy every 10 years. There is nothing magical or superior about a colonoscopy per se as it can also miss colon cancers or polyps as well. Research finds them equally as effective.

The biggest obstacle to preventing colon cancer deaths is that Americans simply don't want to be screened. Colon cancer screening is something I've been passionate about since residency training, when I learned one of my colleague's father died at a young age because of it. Getting my patients to want to have an invasive procedure like a sigmoidoscopy or colonoscopy is incredibly hard.  Yet, I have my 30 second elevator speech nailed.  With Dr. Oz's public campaign, I can refine it even further to this:

If Dr. Oz, arguably a very healthy individual, had a colon polyp, why can't you?

As doctors we need to lead by example. Thanks Dr. Oz for doing the right thing!

Seventy Five Percent of Primary Care Doctors Provide Sub-Standard Colon Cancer Screening Care

A recent article found that primary care doctors the United States are providing sub-standard care when it comes to colon cancer screening. In the Journal of General Internal Medicine, researchers found that 25% of primary care doctors used in office stool testing to screen for colon cancer. Specifically, doctors do a rectal exam and then swipe the rectal contents off their gloves onto a stool testing card. A positive test result indicates the presence of blood, which can be invisible to the naked eye.

The in office stool testing has not been the standard of care for at least a decade. More importantly, it also misses 95% of advanced colon / rectal cancers. The study found that doctors most likely to do the in office stool testing were those in solo practice.

To confuse matters even further, another fifty percent of doctors did both in office stool testing as well as home testing. This means that essentially 75 percent of primary care doctors are using the wrong screening test.

If one is to screen for colon cancer correctly and wishes to use stool card testing, then it must be done by the patient at home, not in the office by the doctor.

If the stool test revealed occult blood, the recommended follow-up is a colonoscopy. A repeat stool test is not suggested. A sigmoidoscopy is also not recommended for a positive stool test result.

Disappointingly, 17.8% of doctors recommend repeating the stool test. If the second stool test was normal, 28.8% recommended no further workup. This is not only wrong, but now falsely assures the patient that everything is fine. Researchers found doctors most likely to recommend a repeat stool test were those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice.

Though this study surveyed doctors from September 2006 to May 2007 and researchers noted that there was slight improvement in colon cancer screening from 2000, (more doctors did not choose sigmoidoscopy after a positive stool test) the results are still quite disturbing.

The correct options for colon cancer screening for Americans at average risk for colon cancer beginning at age 50 include the following:

Fecal occult blood testing (FOBT) -- stool testing which is done at home, not in the office. Done annually.
or
above with flexible sigmoidoscopy every 5 years
or
colonoscopy every 10 years

The authors of the article were too kind when they subtitled their article “serious deviations from evidence based recommendations”. In 2000, when a colleague of mine and I during residency polled our twenty two other family medicine residents and interns, every one correctly knew that in office stool testing was not the standard of care.

The article concludes that “many physicians are continuing to use inappropriate implementation methods [and that] intensified efforts to inform physicians of recommended technique and promote the use of systems for tracking test completion and follow-up are needed.” In other words, if we continue educating doctors perhaps one day they will all do what the standard of care has been for the past 10 years!

Why is this study important?

The only people that can make the healthcare system better is doctors. When we fail, patients get inadequate care.

When healthcare reform proponents recommend patients be given more financial responsibility to get medical care, I wonder if they are too naive. The belief is that the public will choose more prudently when they have more monetary skin in the game. As a result, the thought is that as healthcare becomes more like other markets, consumer goods, purchasing other services, that the healthcare system will be more efficient and drive costs down further.

While I understand that patients should have some cost-sharing, this alone won’t fix the healthcare crisis. Consumer driven healthcare advocates fail to realize that the degree of information needed to make patients truly smart consumers requires a medical degree and training.

Do we expect that patients should be able to recite what are the correct screening modalities for colon cancer screening when doctors can’t do it consistently now even though guidelines have been around for years?

Will patients choose only board-certified doctors or choose quality of medical care based on bedside manner? The correct answer is they should find doctors who have both qualities. If one must choose between the two, patients should opt for board-certification over bedside manner.

This research suggest that perhaps it might be better to find a doctor not in solo practice. Is it possible that doctors are smarter and up to date on the latest research findings because of conversations that occur between patients? Are two heads better than one?

Otherwise, patients have a difficult, but not impossible responsibility to educate themselves. That is why I wrote my book so if our healthcare system truly becomes consumer driven at least there is an easy reference to get everyone up to speed.

You might need to pick up a copy for your own doctor to read.

Can Price Shopping Improve Health Care? Do Pigs Fly?

In a recent Time magazine article Could Price Shopping Could Costs and Improve Health Care, the author suggests as many others have done in the past that forcing patients to more like customers and comparison shop will drive healthcare costs down.

Nothing could be further from the truth.

The theory of consumer driven healthcare goes that if there was more information about the costs of doctors, hospitals, imaging tests, and procedures that people would hunt around to find the best deal, stimulate competition, and drive pricing downward.

Proponents always point to the example of how LASIK eye surgeries have gotten less expensive because of price transparency and increased competition as more eye doctors enter the market in what used to be a very expensive procedure.

But that is always the only example that they give.

They fail to demonstrate how price transparency alone results in decreased costs. Look at elective plastic surgery, which like the LASIK example, has doctors providing a service which isn't medically necessary. Shop around. Get pricing. Has plastic surgery gotten less expensive like LASIK surgery? Of course not. Why?

In the past, LASIK eye surgery required the very skilled hands of an ophthalmologist. Over many years, however, understanding precisely who made a good candidate and the optimal surgical technique to be used become more clear. Consequently the procedure became standardized. As a result, these days LASIK surgery is typically performed by an machine that is essentially automated under the supervision of an ophthalmologist. Because of this standardization and precision, LASIK surgeries are done more reliably and quickly for those who are good candidates. For those of us who have conditions that don't fit into this neat workflow, we will still need to rely on the human doctor's expertise and experience. In those situations, the pricing won't be inexpensive.

It isn't price transparency alone that will drive costs down, but the standardization of treatments for a particular ailment. Specific treatments for bladder infections (urinary tract infections), sore throat, like strep throat or mono, pink eye (conjunctivitis) are fairly clear cut and straight forward. This is why walk-in clinics like Minute Clinic can drive costs downward using less expensive physician assistants and nurse practitioners, rather than doctors. For sore throat, the workflow is pretty obvious (and available at www.familydoctors.org).

Note how they avoid back pain and chest pain. It may be for liability issues, but also because the amount of precision needed isn't quite there. Once medical science can determine which tests or interventions can reliably differentiate a symptom or problem into a specific treatment will costs come down. This is probably why plastic surgery won't quite ever become a commodity like LASIK surgery. How would you like to have a standardized nose job or face lift?

Proponents of consumer driven healthcare also believe that having patients pay more of their healthcare expensive or "having more skin in the game", will also drive costs down over the long-term. The thinking goes that if people understood the high costs of having a chronic illness like diabetes or heart disease that they would choose healthy behaviors. They should appreciate that preventive interventions like cancer screenings were less expensive than dealing with a cancer diagnoses and subsequent treatment. Getting a simple vaccination to prevent influenza or pneumonia would be far better in preventing emergency room visits or hospitalizations. People would begin to make rational choices and opt for less costly therapies today to put off very expensive theoretical losses in the future.

Odds this will occur? Highly unlikely.

Simply look at how the American consumer fared when given financial responsibility to make decisions presumably for their best interest, retirement planning, to determine how successful the public might be in embarking on consumer driven healthcare.

Starting in the 1970s, employers started to shift employees from pension plans (defined benefit plans) to 401(k) plans (defined contribution plans), where employees would have more financial responsibility and have "more skin in the game" in determining how much to save and how to invest for retirement. The thinking was that employees, looking out for their best interest, would do research and demonstrate the rational behavior needed to ensure that they retired with a nest egg that suited their needs. After all, who would have more motivation to save for retirement than the individual himself?

Did it work out as planned?

A recent article from CNN Money found that 43 percent of Americans have less than $10,000 saved for retirement. More importantly "the gap between what Americans have saved and what they'd need for retirement is forcing workers to prolong their working years."

In other words, the American consumer isn't doing well to save for retirement even though it is in his best interest. At least in retirement planning, consumers have the option of delaying retirement and working longer.

Consumers as patients, however, won't have that luxury of putting off medical care if they suddenly become ill. It is very likely a large number of Americans instead of losing weight and controlling blood pressure will have a devastating heart attack that requires open heart surgery. Colon cancers will be detected at later incurable stages requiring very expensive chemotherapy for months rather than having been removed years earlier with less costly colonoscopies. It is very likely in consumer driven healthcare, much like defined contribution retirement plans, that the consumer or patient hasn't saved enough to pay for these very expensive future therapies or treatments.

As a graduate of the Wharton School of Business, however, I wouldn't do my education justice if I completely dismissed the concept of efficient markets, consumerism, and competition. If consumer driven healthcare is to work, it will require a few elements, which unfortunately the American healthcare system at this time is ill equipped to deliver on.

I will discuss these crucial elements in a future post.

Breast Cancer Screening with Mammograms at age 40? 50? Who is the USPSTF?

When the U.S. Preventive Services Task Force (USPSTF) updated their recommendations and were against routine mammography for women aged 40 to 49, it certainly got a lot of attention. These guidelines are far different than those advocated by the American Cancer Society (ACS) which recommends screening starting at age 40 with annual mammograms.

• Who is the USPSTF?
• What does their recommendations mean for women?
• Why is there conflicting recommendations?

Who is the USPSTF?

The U.S. Preventive Services Task Force (USPSTF) is an independent committee of primary care and preventive physicians that periodically reviews the latest medical research and recommends tests and screening methods that have scientifically been shown to make a difference. As a result, its recommendations are the most conservative of any national organization.

The USPSTF’s recommendations are considered the “gold standard” for determining which clinical services are preventive. They review and look at various screening tests and preventive medications to determine whether there’s proof these interventions work and that the benefits they provide outweigh the potential harm. USPSTF indicates how strongly it recommends a particular method with a letter grade designation (A, B, C, D, and I). An A recommendation means that USPSTF strongly recommends that doctors provide a particular service to eligible patients. A B rating is simply a recommendation. A C means the task force recommends against routinely providing the service, but leaves the decision to the discretion of the individual doctor and patient. A D rating means the group recommends against providing for a particular intervention. An I recommendation indicates that there is not enough evidence to determine whether to recommend for or against a particular procedure.

The USPSTF recommendations tend to be the most conservative of any national organization, because they look for interventions that have proven benefits backed by research. Therefore, promising new technologies and tests that are yet unproven (and at times remain unproven or shown to be no better than existing tests) will not be recommended. As a result, the USPSTF’s guidelines may lag behind those of other organizations. But because they set such a high standard before recommending a particular treatment, insurers should cover the tests and procedures rated A and B.

From the November 2009 update on breast cancer screening update, the USPSTF recommended:

• Against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
  

• Recommended biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.
  

• Against teaching breast self-examination (BSE). Grade: D recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  

• Insufficient evidence to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

What does this mean for women?

First, that there is some evidence that screening between ages 40 to 49 for breast cancer among women with average risk may not be as beneficial as we previously thought. There has been evidence from other countries, like Canada, which have suggested that. However, it is highly unlikely that the American Cancer Society (ACS), being an advocacy group for cancer awareness will change their stance. They said as much with the following:

The USPSTF says that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. Yet USPSTF also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.

The American Cancer Society neglects to mention the potential number of extra women harmed with the extra screening between age 40 to 49. An additional 565 women need to be screened above and beyond the 1,339 women to save one life. Within this additional group, many women will have abnormal mammograms and require breast biopsies only to discover that the results were normal. The mammogram was a false-positive.

The USPSTF found in a study in the Annals of Internal Medicine, funded by the National Cancer Institute, that screening every other year achieved over 80 percent of the benefit of screening annually while cutting the false-positive result by nearly half. While every other year screening from age 50 to 69 years resulted in about a median 16.5% (range, 15% to 23%) decrease in breast cancer deaths compared to no screening, starting mammogram at age 40 decrease the death rate further by 3 percent, but increased the costs as more false-positive cases occurred. This article helped influence their recent decision.

Realistically for women, since ACS will not change their recommendation, is that mammograms will still be a covered benefit for any woman who desires to have a mammogram as early as age 40 and can be repeated annually.

What does this mean for you? If you are worried about breast cancer, consider getting screened starting at age 40, however, the benefit of screening may not be as good as we first thought. Certainly if there is a family history of breast cancer, you should discuss with your doctor whether mammography is enough or whether a breast MRI is needed.

Why are there conflicting information?

This won't be the first time USPSTF will have different recommendations than groups like ACS or other professional medical associations. Reasonable doctors and researchers can look at the same data and have different results. It speaks to the problem of screening for cancers and the tools that we currently have. The amount of precision that we would like as patients and doctors in identifying which group of individuals truly need a screening intervention and who does not have yet to be discovered. USPSTF and ACS disagree a bit on colon cancer screening as well. For example, when it comes to colon cancer screening USPSTF gives a grade A recommendation and suggests that:

Using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods may vary.

Yet, ACS also recommends virtual colonoscopy or stool DNA testing as reasonable alternatives even though there is no proof they save lives.

Stay tuned. Medical science continues to evolve and recommendations continue to change. The the mean time, exercise regularly, don't smoke, eat five servings of fruits and vegetables daily, and you might extend your life by an additional 14 years!

Your most crucial and trusted relationship is between you and your doctor. Questions? Speak up and ask. Don't be scared. Be informed.

Virtual Colonoscopy? Just Say No

The Center for Medicare and Medicaid Services -- CMS -- is asking for public input on whether virtual colonscopy - CT scanning of the colon -- should be a covered benefit in Medicare to screen for colon cancer.

In early 2008, the American Cancer Society (ACS) added virtual colonoscopy as well as stool DNA testing on its list of suggested screening methods for colon cancer. Screening for colon cancer is recommended for all adults 50 years and older. Besides these two options, the others are:

• fecal stool testing (FIT or FOBT) annually
• double contrast barium enema every 5 years
  
• flexible sigmoidoscopy every 5 years
• colonoscopy every 10 years

While I understand why ACS recommended adding virtual colonoscopy to its list, I don't agree with them. Although it is not as invasive as a sigmoidoscopy or colonscopy since patients lay on the CT scanner table while an x-ray technician works the machines to allow xrays to peer into the body, the colon preparation as well as the insufflation of air to distend the colon, is still required. Also, there is exposure of radiation which increasingly a question doctors are facing. Is doing a scan worth the risk of radiation exposure and potentially higher risk of cancer?

More importantly, if a colon polyp or growth is seen on the virtual colonoscopy, patients still need to have an invasive procedure - sigmoidoscopy / colonoscopy - to do a biopsy or removal of the lesion in question. At least these procedures don't involve any radiation as the instrument is essentially a fiber optic cable.

With the healthcare crisis upon us and the nation asking itself what is affordable and reasonable and what is not, CMS hopefully will not recommend virtual colonoscopy to be added to its list of covered benefits. While the technology is attractive, there are other proven screening tests that albeit uncomfortable are life-saving and don't subject people to unnecessary radiation.

Colonoscopies Miss Colon Cancer

A report in the Journal of the American Medical Association found that flat colon polyps, which are harder to see than raised polyps, were ten times more likely to be cancer. Japanese gastroenterologists found these harder to detect flat polyps by using a dye during colonoscopy. The study also found that having a colonoscopy wasn't enough for adequate screening, but rather how much time and care the doctor took to examine the colon. From the report:

• The growths tend to be smaller when they are cancerous — the size of a nickel instead of a quarter — and are level with the colon wall or depressed like a pothole. They blend in with the surrounding tissue and are difficult to spot.
• While knobby polyps were found in four times as many participants, more than half the colon cancers found — 15 of 28 — were in flat and depressed growths. Thirteen were in polyps.
• Undetected flat growths could explain some mysterious "interval cancers" that show up between screenings in people who have regular colonoscopies, experts said.

Currently the recommended guidelines for colon cancer screening include having a colonoscopy every 10 years starting at the age 50. Recently updated colon cancer screening guidelines from the American Cancer Society now include virtual colonoscopy as well as a stool DNA test. These two newer techniques join screening by using a flexible sigmoidoscopy every 5 years with or without annual stool testing for occult blood or screening via a barium enema. For individuals at average risk (i.e. no family history of colon cancer or no personal history of medical problems like ulcerative colitis that increases an individual's risk of colon cancer greatly), any one of these interventions should begin at age 50.

While I understand the addition of a virtual colonoscopy, which may be more acceptable for the public to accept rather than having a endoscope inserted into the colon for evaluation, I'm not so sure that the radiation exposure related to this screening test is justified. I suspect in the end it was added because:

• The biggest issue is not which screening a patient should get, but that patients come in for screening. All colon cancer deaths can be averted through screening and early treatment, but only 30 percent of people recommended to get screenings actually do, according to the Cancer Society.

• "The challenge we have is getting people to participate in screenings," said Jack Mandel, an Emory University epidemiologist who has studied colon cancer screening tests. "We can prevent these deaths."

What You Must Do to Stay Healthy

The American healthcare system only consistently delivers the right preventive care 55 percent of the time. As a result, tens of thousands of Americans die prematurely from avoidable deaths because simple interventions weren't done. Doctors are increasingly busy and may not have enough time to tell you all you need to know to stay well. One study showed that a doctor working full time would need an extra day to counsel patients on what steps they should do to keep healthy. As a result preventive screening tests for cancers like breast cancer, prostate cancer, and colon cancer, which are leading causes of death, aren't performed routinely and regularly for those who need it. With more patients paying higher deductibles and co-pays, you must know what you should ask for and then get it done.

For breast cancer screening, this means women at average risk should have a mammogram at age 40. Men at average risk should begin screening for prostate cancer at age 50. Both genders should have colon cancer screening, either a sigmoidoscopy with annual stool testing or a colonoscopy starting at age 50. You may need to check with your doctor if you are at higher risk as you may need to be screened earlier or more frequently. A major misconception is that only individuals with a family history are at risk for cancer. While they are at higher risk, the vast majority of new cancer cases occur in individuals without a family history.

The same preventive screening tests and interventions also apply to other problems like high blood pressure, high cholesterol, and diabetes. Do you know what the ideal blood pressure is? How often should you have it checked? When should you be screened for diabetes? Are you at risk?

Even if you exercise regularly, are at a healthy weight, don't smoke or drink, it doesn't mean you can or should skip these important preventive steps. Identifying and addressing problems early increases your chance of living longer and staying well.

The healthcare system doesn't reliably remind you when you should get these tests done. Your doctor may not have enough time to remind you what to do. Increasingly you are paying more for healthcare. Find out what you need to do to stay well. It's your money. It's your life.

Go to www.davisliumd.com to get the preventive guidelines for adults under the free download section.

Healthcare Failings Due to Not Doing the Basics

For anyone interested in understanding what drives a lot of the costs in the healthcare system, the New York Times health series about the six killers in America, heart disease, cancer, stroke, chronic obstructive pulmonary disease (emphysema), diabetes, and Alzheimer's is an excellent place to start.

Some themes begin to emerge. For heart disease, the way to prevent future heart attacks is to ensure that patients understand how to take their medications and that it is often for life. For successful cancer treatment, the goal is early detection and undergoing the simple, but for some, unpleasant tests to screen for breast, colon, and prostate cancer. For stroke, it is to ensure that missed opportunities aren't missed.

Ulimately, much of the differences between a fair outcome and great outcome is focusing on the little things - taking medications regularly and as directed, getting the preventive screening tests done, and making sure that the little things are always taken care of.

Much like any coach knows before a team can be successful, each of the players must know the fundamentals. In hockey that would be skating, stickhandling, passing, and checking. It doesn't matter how expensive your skates are or what high tech materials your stick is made out of. Unless you and your team know the basics, you will fail. Unfortuantely, the healthcare system as a whole hasn't yet mastered the fundamentals.

Breast Cancer and Colon Cancer Treatment and Survivorship Guides -- A Good Idea

The American Society of Clinical Oncologists (ASCO) last month announced that they would have suggested treatment plans and summaries for breast cancer and colon cancer care as well as a survivorship plan available on their website. The former is for oncologists and the latter is for their patients. The treatment plan and summary, which consists of two pages will help oncologists summarize and review important clinical information and well as pre and post chemotherapy information to make it easier to deliver care. These forms were not intended to replace the usual detailed medical documentation, history taking, physical examination, and assessments that oncologists already were accustomed to doing.

While it remains to be seen how doctors will feel about the treatment plan and summary forms, breast cancer as well as colon cancer patients will like the one page survivorship plan. Treatment of cancer is already a complicated and potentially confusing process with many different treatments, dates treatments are given, and when the various office visits and follow-up tests are needed. The survivorship plan provides a basic road map so that an individual patient will have a basic idea of what to expect over the next few weeks, months, and years. It was recommended that the details of the plan should be tailored to the individual's unique circumstances.

This initial effort is a step in the right direction. With doctors busier and more rushed than in the past and patients faced not only with the emotional impact of coping with cancer as well as the logistical challenges of getting treatment, these forms provide a starting point of conversation between oncologists and patients. Already ASCO is working on developing treatment summary plans and survivorship plans for other cancers.

If you or a loved one has been recently diagnosed with breast cancer or colon cancer, download the relevant survivorship plan (and even the treatment plan and summary form) and bring it to your oncologist. It can only help you navigate through what is often a trying and confusing time.