Tests and procedures
Fewer men are being given PSA tests to screen for prostate cancer. As screening rates have fallen, so have the number of prostate cancer diagnoses. This probably also means that fewer men are receiving potentially unnecessary treatment, with its attendant negative side effects. At the same time, it isn’t yet clear whether that comes at the cost of more aggressive cancers being caught at an incurable stage. Better screening tests may make the difference in helping strike the right balance between limiting harm and preventing prostate cancer deaths.
CT scans, MRIs, and PET scans are among the many advanced imaging options available to doctors and patients today. Although these tests have revolutionized medical care, they also come at a cost. But not only are these tests expensive — many of them expose patients to radiation, and all of them can reveal potential problems that turn out to be harmless, but require follow-up tests to be sure. Rather than have insurance companies act as gatekeeper, it may be more effective to have clinicians consult with imaging experts when deciding on which, if any, tests are necessary.
The age at which women should start having screening mammograms, and how often, has been controversial for some time. Reputable national organizations have differed in their recommendations. Accumulating data suggest that for women under 45, screening mammograms may bring more harm than good. As a result, the American Cancer Society has radically shifted its screening guidelines for women in their early 40s at an average risk for breast cancer.
Last month, JAMA Oncology published a study that suggests standard treatment for non-invasive breast cancer (DCIS) may be too aggressive and that perhaps some women with DCIS would do just as well without lumpectomy or mastectomy. As expected, this has generated a lot of controversy and confusion. For some women, DCIS is a “precursor” to invasive breast cancer, but in many others, it may not progress. But right now, doctors don’t understand these cancers well, and it is difficult to predict how these abnormal cells will behave in any given woman. More research is needed to determine optimal treatment for each individual woman diagnosed with DCIS. In the meantime, a woman with DCIS and her doctor should take into account certain risk factors (age and race among them), as well as that woman’s personal preferences when creating a treatment plan.
Last spring, an advisory panel for the Center for Medicare and Medicaid Services (CMS) recommended that Medicare not cover low-dose CT scans for smokers or former smokers. These scans can double the proportion of lung cancers found at an early stage, while they are still treatable. Yesterday, CMS announced that it would cover the cost of these scans for people between the ages of 55 and 74 who smoke, or who quit within the last 15 years, and who have a smoking history of 30 pack-years. (That means a pack a day for 30 years, two packs a day for 15 years, etc.) The new Medicare plan would cover scans for an estimated 4 million older Americans, at a cost estimated to be more than $9 billion over five years. In a wise addition, Medicare will require smokers to get counseling on quitting or the importance of staying smoke-free before having the annual scan.
More and more experts now recommend that people with high blood pressure regularly check their blood pressure at home. Doing this gives people an idea where their blood pressure stands in between office visits, and can motivate them to care more about their health. It also helps doctors make quick medication adjustments to keep blood pressure in the healthy zone. But according to a new study, up to 15% of home blood pressure monitors as accurate as they should be. Readings can be off by as much as 20 points. If you check your blood pressure at home, bring your monitor and cuff to your doctor’s office and compare the reading you get with the doctor’s known, accurate instrument.
A heart attack in progress is a medical emergency. The leading way to stop it is with artery-opening angioplasty. But many angioplasties are done for reasons other than heart attack. Some are performed to ease chest pain that appears with physical activity or stress. This is the chest pain known as stable angina. Sometimes the prospective patient has no symptoms at all — just test results that indicate one or more clogged arteries. Cardiologists continuously debate when it’s appropriate to do non-emergency angioplasty. Two studies in JAMA Internal Medicine add some provocative new information: that incomplete or even misleading advice from doctors contributes to unnecessary angioplasties. And that’s a problem because angioplasty can harm as well as help.
Screening — checking a seemingly healthy person for signs of hidden disease — is an important part of routine medical care. It is done for various types of cancer, heart disease, diabetes, and other chronic conditions. Screening makes sense when finding and treating a hidden condition will prevent premature death or burdensome symptoms. But it doesn’t make sense when it can’t do either. That’s why experts recommend stopping screening in older individuals, especially those who aren’t likely to live another five or 10 years. Yet an article published online in JAMA Internal Medicine shows that many doctors still recommend cancer screening tests for their older patients. Many don’t benefit, and some are even harmed by the practice. Asking people who can’t benefit from a cancer screening test to have one is a waste of their time and money, not to mention a waste of taxpayer money (since these tests are usually covered by Medicare). Screening tests can also cause physical and mental harm. Decisions about cancer screening should be mutually made by an individual and his or her doctor. Equally important, the person should be well informed about the risks of the test and about what will happen if a test suggests there may be cancer that won’t shorten the his or her life.
The annual pelvic exam, an oft-dreaded part of preventive care for women, may become the as-needed pelvic exam, thanks to new guidelines from the American College of Physicians. For decades, doctors have believed this exam may detect problems like ovarian cancer or a bacterial infection even if a woman had no symptoms. But an expert panel appointed by the American College of Physicians now says that healthy, low-risk women do not need to have a pelvic exam every year. The exam isn’t very effective at finding problems like ovarian cancer or a vaginal infection, and it often causes discomfort and distress. Sometimes it also leads to surgery that is not needed. The new guidelines only apply to the pelvic exam, and only in healthy women.
Today is National Hepatitis Testing Day. The point of this day is to raise awareness of viral hepatitis, a condition that can lead to liver failure, liver cancer, and death. Early detection of hepatitis in the millions of people who have it but don’t know it can protect them from its harms and keep them from spreading the infection to others. There are five main types of viral hepatitis: A, B, C, D, and E. Some hepatitis viruses make people sick soon after infection but don’t cause long-term harm. Others are mostly silent, but stay active in the liver for years, possibly causing long-term damage. Advances in testing and treatment make early diagnosis more important today than it has ever been.