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.
Tests and procedures
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.
A new report from the Alzheimer’s Association says that as many as 5 million Americans have Alzheimer’s disease or some other form of dementia. Every 67 seconds someone in the United States develops Alzheimer’s disease or dementia. That’s 470,000 Americans this year alone. Given that these thieves of memory and personality are so common and so feared, should all older Americans be tested for them? In proposed guidelines released yesterday, the U.S. Preventive Services Task Force said “no.” Why not? Even after conducting a thorough review of the evidence, the panel said that there isn’t enough solid evidence to recommend screening, especially since not enough is known about the benefits and the harms. In part, the recommendation is based on the sad fact that so far there aren’t any truly effective approaches to stop the forward progress of dementia.
There’s no question that tests to detect cancer before it causes any problems can save lives. But such tests can also cause harm through overdiagnosis and overtreatment. A study published yesterday in JAMA Internal Medicine indicates that the majority of people aren’t informed by their doctors that early warning cancer tests may detect slow-growing, or no-growing, cancers that will never cause symptoms or affect health. Undergoing surgery, chemotherapy, or radiation for such cancers provides no benefits and definite harms. The researchers found that only 9.5% of people were informed by their doctors of the risk of overdiagnosis and possible overtreatment. Compare that to 80% who said they wanted to be informed of the possible harms of screening before having a screening test. Informing patients about the risks of screening isn’t easy to do in a brief office visit. It’s complicated information. And the researchers suggest that many doctors don’t have a good grip on relative benefits and harms of screening.
Proposed recommendations from the influential U.S. Preventive Services Task Force call for annual CT scans for some current and former smokers. Implementing these recommendations could prevent an estimated 20,000 deaths per year from lung cancer. The task force suggests annual testing for men and women between the ages of 55 and 79 years who smoked a pack of cigarettes a day for 30 years or the equivalent, such as two packs a day for 15 years or three packs a day for 10 years. This includes current smokers and those who quit within the previous 15 years. According to the draft recommendations, which were published today in the Annals of Internal Medicine, the benefits of annual checks in this group outweighs the risks. According to the Task Force recommendations, not all smokers or former smokers should undergo yearly CT scans. This group includes smokers or former smokers who are younger than 55 or older than 79, who smoked less or less often than a pack of cigarettes a day for 30 years or the equivalent, who quit smoking 15 or more years ago, or who are too sick or frail to undergo treatment for lung cancer. These draft recommendations have been posted for public comment until August 26, 2013.
New Jersey Governor Chris Christie’s revelation yesterday that he had secretly undergone weight-loss surgery back in February shouldn’t come as a big surprise. He has been publicly (and privately) struggling with his weight for years and fits the profile of a good candidate for this kind of operation. In general, weight-loss surgery is appropriate for people with a body mass index (BMI) of 40 or higher, as well as for those with a BMI of 35 to 39.9 and a severe, treatment-resistant medical condition such as diabetes, heart disease, and sleep apnea, who had tried to lose weight other ways. Christie had a BMI of at least 41. He also acknowledged trying to lose weight many times, using different weight loss programs. He underwent laparoscopic gastric banding, also known as lap banding. There are also two other types of weight-loss surgery, gastric bypass and the gastric sleeve procedure.
Living through the physical and emotional toll of breast cancer is so traumatic that some women can’t bear the thought of doing it again. That’s why a growing number of women who have already been diagnosed with cancer in one breast are taking the drastic measure of having both breasts removed (a procedure called prophylactic mastectomy). Yet a University of Michigan study presented last week at the American Society of Clinical Oncology’s Quality Care Symposium showed that nearly three-quarters of women who had this procedure were actually at very low risk of developing cancer in the healthy breast. In other words, many women are unnecessarily exposing themselves to the potential risks of a double mastectomy—including pain, infection, and scarring. The new study suggests that more and better information about breast cancer recurrence—and the risks and benefits of prophylactic mastectomy—are needed as women consider this procedure.
Researchers at Kansas State University have developed a blood test that rapidly detects breast cancer (as well as non-small cell lung cancer) in very early stages, long before symptoms appear or the cancer can be seen by other methods. The experimental test identifies enzyme patterns that differ from one type of cancer to another. According to the researchers, the test can detect very early breast cancers (stages 0 and 1), as well as early lung cancers (stages 1 and 2), within an hour, with 95% accuracy. However, they tested only 32 participants with various stages of breast or lung cancer, as well as 12 people without cancer. Whether finding cancer that early makes a difference for treatment and survival remains to be seen.