Saturday, October 29, 2011

M.R.I.’s, Often Overused, Often Mislead, Doctors Warn -

Dr. James Andrews, a widely known sports medicine orthopedist in Gulf Breeze, Fla., wanted to test his suspicion that M.R.I.'s, the scans given to almost every injured athlete or casual exerciser, might be a bit misleading. So he scanned the shoulders of 31 perfectly healthy professional baseball pitchers.

The pitchers were not injured and had no pain. But the M.R.I.'s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. "If you want an excuse to operate on a pitcher's throwing shoulder, just get an M.R.I.," Dr. Andrews says.

He and other eminent sports medicine specialists are taking a stand against what they see as the vast overuse of magnetic resonance imaging in their specialty.

M.R.I.'s can be invaluable in certain situations — finding serious problems like tumors or helping distinguish between competing diagnoses that fit a patient's history and symptoms. They also can make money for doctors who own their own machines. And they can please sports medicine patients, who often expect a scan.

But scans are easily misinterpreted and can result in misdiagnoses leading to unnecessary or even harmful treatments.

For example, said Dr. Bruce Sangeorzan, professor and vice chairman of the department of orthopedics and sports medicine at the University of Washington, if a healthy, uninjured person goes out for a run, a scan afterward will show fluid in the knee bone. It is inconsequential. But in an injured person, fluid can be a sign of a bone that is stressed or even has a crack and is trying to heal.

"An M.R.I. is unlike any other imaging tool we use," Dr. Sangeorzan said. "It is a very sensitive tool, but it is not very specific. That's the problem." And scans almost always find something abnormal, although most abnormalities are of no consequence.

"It is very rare for an M.R.I. to come back with the words 'normal study,' " said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. "I can't tell you the last time I've seen it."

In sports medicine, where injuries are typically torn muscles or tendons or narrow cracks in bones, specialists like Dr. Andrews and Dr. DiGiovanni say M.R.I.'s often are not needed — they usually can figure out what is wrong with just a careful medical history, a physical exam and, sometimes, a simple X-ray.

M.R.I.'s are not the only scans that are overused in medicine but, in sports medicine, where many injuries involve soft tissues like muscles and tendons, they rise to the fore.

In fact, one prominent orthopedist, Dr. Sigvard T. Hansen, Jr., a professor of orthopedics and sports medicine at the University of Washington, says he pretty much spurns such scans altogether because they so rarely provide useful information about the patients he sees — those with injuries to the foot and ankle.

"I see 300 or 400 new patients a year," Dr. Hansen says. "Out of them, there might be one that has something confusing and might need a scan."

The price, which medical facilities are reluctant to reveal, depends on where the scan is done and what is being scanned. One academic medical center charges $1,721 for an M.R.I. of the knee to look for a torn ligament. The doctor who interprets the scan gets $244. Doctors who own their own M.R.I. machines — and many do — can pocket both fees. Insurers pay less than the charges — an average of $150 to the doctor and $960 to the facility.

Steve Ganobcik is something of a poster child for what can go wrong with the scans. A salesman who turns 44 on Saturday, Mr. Ganobcik twisted his knee skiing in Colorado in February. He continued skiing anyway and skied again the next two days as well, not wanting to cut his vacation short.

When he got home to Cleveland, his knee still bothered him, so he saw a sports medicine orthopedist. The doctor immediately ordered an M.R.I. and said it showed a torn anterior cruciate ligament, or A.C.L. It is one of the most common — and most devastating — sports injuries. The standard treatment is surgery, with a difficult recuperation lasting six months to a year.

Mr. Ganobcik looked into surgical techniques and decided he wanted a different one than the one his doctor offered. So he saw another sports medicine orthopedist who, agreeing that Mr. Ganobcik's ligament was torn, scheduled the operation.

Meanwhile, Mr. Ganobcik heard that Dr. Freddie H. Fu, chairman of the division of sports medicine at the University of Pittsburgh, had what might be an even better technique, so he went to see him.

To Mr. Ganobcik's surprise, Dr. Fu told him his ligament was not torn after all. His pain was from a fracture in a long bone in the lower leg that the other doctors had also noticed was broken. An M.R.I. at the University of Pittsburgh confirmed it, showing a perfectly normal A.C.L. (Dr. Fu adds that Mr. Ganobcik's original scans had an image that was ambiguous. He wanted a better one, to see if Mr. Ganobcik's ligament had been partly torn and was healing or had never been torn at all. He would not need surgery with a partial tear, but he would need more careful recuperation.)

Dr. Fu's suspicions were raised by Mr. Ganobcik's story. He could never have continued skiing with a torn A.C.L. The diagnosis "made no sense," Dr. Fu said.

And that, Dr. Fu says, illustrates a common problem: relying on an M.R.I. instead of a history and an exam. Dr. Fu's diagnosis "was a shock," Mr. Ganobcik said. "I thought he was going to talk about options for surgery."

M.R.I.'s can be extremely useful in sports medicine, said Dr. Andrew Green, the chief of shoulder and elbow surgery at Brown University. But, he says, there is a fine line between appropriate use and overuse.

That, at least, is what he found in one of the few studies to address the issue. The ideal study would randomly assign patients to have scans or not and then assess their outcomes. Such a study has not been done. Instead, a few researchers asked if scans made a difference for people who happened to have them. They found they did not — at least in two common situations.

Dr. Green and his colleagues reviewed the records of 101 patients who had shoulder pain lasting at least six weeks and that had not resulted from trauma, like a fall. Forty-three arrived bearing M.R.I.'s from a doctor who had seen them previously. The others did not have scans. In all cases, Dr. Green made a diagnosis on the basis of a physical exam, a history, and regular X-rays.

A year later, Dr. Green re-assessed the patients. There was no difference in the outcome of the treatment of the two groups of patients despite his knowledge of the findings on the scans. M.R.I.'s, he said, are not needed for the initial evaluation and treatment of many whose shoulder pain does not result from an actual injury to the shoulder.

Dr. DiGiovanni did a similar study with foot and ankle patients, looking back at 221 consecutive patients over a three-month period, 201 of whom did not have fractures. More than 15 percent arrived with M.R.I.'s obtained by doctors they had seen before coming to Dr. DiGiovanni. Nearly 90 percent of those scans were unnecessary and half had interpretations that either made no difference to the patient's diagnosis or were at odds with the diagnosis.

"Patients often feel like they are getting better care if people are ordering fancy tests, and there are some patients who come in demanding an M.R.I. — that's part of the problem," he said.

Some doctors might also feel they are providing better care if they order the scans, Dr. DiGiovanni said, and doctors often feel that they risk malpractice charges if they fail to scan a patient and then miss a diagnosis.

Dr. Hansen teaches his fellows — doctors in training — to be careful with scans and explains the risks of making the wrong diagnosis if they order them unnecessarily. He also knows it is not easy to refrain from ordering an M.R.I.

It's different for him, Dr. Hansen says. He is so eminent that patients tend not to question him.

"When I say 'You don't need a scan,' then it's over," Dr. Hansen said. His fellows get a different response. Patients, he says, "look at them like, 'You don't know what you're doing.' "

Thursday, October 27, 2011

How much is that surgery in the window? - The Washington Post

We know that, in the aggregate, health care costs us a lot: about $2.5 trillion annually, or 17 percent of our gross domestic product.

But what about all the things that go into that $2.5 trillion? How much does each test, treatment and medical procedure actually cost? The Government Accountability Office recently tried to ask hospitals and doctors that question. It wanted to go beyond the numbers that insurance subscribers usually see, like the co-pays and deductibles associated with a given procedure, and get the total dollar cost. The agency didn't have much luck. 

Even with a number of health cost transparency efforts underway, it's still incredibly difficult to find out how much money is spent on specific medical treatments.

For its study, the GAO contacted 17 randomly selected hospitals to ask how much a knee replacement, a very common surgery, would cost. Here's what they heard back: "None of the hospital representatives could provide a complete cost estimate for a full knee replacement, meaning the price given was not reflective of any negotiated discounts, was not inclusive of all associated costs, and did not identify consumers' out-of-pocket costs."

Physicians did slightly better: when the GAO contacted 18 doctors to ask how much a diabetes screening would cost, four came up with a complete price estimate.

Health industry players are trying to make prices more transparent but not having huge success. The GAO surveyed eight health cost transparency efforts that range from an online Medicare tool to compare hospitals to a tool operated by the health plan Aetna, called the "Member Payment Estimator," that provides cost estimates for more than 500 physician and hospital services.

Across the board, the GAO review doesn't come up with much to celebrate. Only two provide an estimate of the total cost of a given episode of care.

There's a whole host of obstacles that stand in the way of transparent health care pricing. A big one has to do with health providers long considering health care costs proprietary. Both insurers and hospitals have strong business incentives not to publish health cost figures. "If a hospital was aware that another hospital negotiated a higher rate with the same insurance company, then the lower-priced hospital could seek out  higher negotiated rates which may eliminate the first hospital's competitive advantage," the GAO explains. On the flip side, insurers don't want their competitors to know if they're getting the same hospital services for a cheaper price.

This could start changing soon: 30 states are weighing legislation to increase price transparency in health care, according to a recent review in the New England Journal of Medicine. The end game of these initiatives isn't exactly clear. Would consumers change their health care behaviors if they had more information on cost? "Most patients are insured, so they pay very little of the cost of their medical care, which dramatically weakens or eliminates their incentive to choose a lower-cost provider," Harvard's Anna Sinaiko and Meredith Rosenthal have written. Other factors, like quality and convenience, also play a role in our health care decisions. If state legislatures do start passing these laws, we might soon know more about how much cost matters when it comes to where Americans get care.

Tuesday, October 25, 2011

The Limits of Breast Cancer Screening -

Has the power of the mammogram been oversold?

At a time when medical experts are rethinking screening guidelines for prostate and cervical cancer, many doctors say it's also time to set the record straight about mammography screening for breast cancer. While most agree that mammograms have a place in women's health care, many doctors say widespread "Pink Ribbon" campaigns and patient testimonials have imbued the mammogram with a kind of magic it doesn't have. Some patients are so committed to annual screenings they even begin to believe that regular mammograms actually prevent breast cancer, said Dr. Susan Love, a prominent women's health advocate. And women who skip a mammogram often beat themselves up for it.

"You can't expect from mammography what it cannot do," said Dr. Laura Esserman, director of the breast care center at the University of California, San Francisco. "Screening is not prevention. We're not going to screen our way to a cure."

new analysis published Monday in Archives of Internal Medicine offers a stark reality check about the value of mammography screening. Despite numerous testimonials from women who believe "a mammogram saved my life," the truth is that most women who find breast cancer as a result of regular screening have not had their lives saved by the test, conclude two Dartmouth researchers, Dr. H. Gilbert Welch and Brittney A. Frankel.

Dr. Welch notes that clearly some women are helped by mammography screening, but the numbers are lower than most people think. The Dartmouth researchers conducted a series of calculations estimating a woman's 10-year risk of developing breast cancer and her 20-year risk of death, factoring in the added value of early detection based on data from various mammography screening trials as well as the benefits of improvements in treatment. Among the 60 percent of women with breast cancer who detected the disease by screening, only about 3 percent to 13 percent of them were actually helped by the test, the analysis concluded.

Translated into real numbers, that means screening mammography helps 4,000 to 18,000 women each year. Although those numbers are not inconsequential, they represent just a small portion of the 230,000 women given a breast cancer diagnosis each year, and a fraction of the 39 million women who undergo mammograms each year in the United States.

Dr. Welch says it's important to remember that of the 138,000 women found to have breast cancer each year as a result of mammography screening, 120,000 to 134,000 are not helped by the test.

"The presumption often is that anyone who has had cancer detected has survived because of the test, but that's not true," Dr. Welch said. "In fact, and I hate to have to say this, in screen-detected breast and prostate cancer, survivors are more likely to have been overdiagnosed than actually helped by the test."

How is it possible that finding cancer early isn't always better? One way to look at it is to think of four different categories of breast cancer found during screening tests. First, there are slow-growing cancers that would be found and successfully treated with or without screening. Then there are aggressive cancers, so-called bad cancers, that are deadly whether they are found early by screening, or late because of a lump or other symptoms. Women with cancers in either of these groups are not helped by screening.

Then there are innocuous cancers that would never have amounted to anything, but they still are treated once they show up as dots on a mammogram. Women with these cancers are subject to overdiagnosis — meaning they are treated unnecessarily and harmed by screening.

Finally, there is a fraction of cancers that are deadly but, when found at just the right moment, can have their courses changed by treatment. Women with these cancers are helped by mammograms. Clinical trial data suggests that 1 woman per 1,000 healthy women screened over 10 years falls into this category, although experts say that number is probably even smaller today because of advances in breast cancer treatments.

Colin Begg, head of the department of epidemiology and biostatistics at Memorial Sloan-Kettering Cancer Center in New York, said that he supports mammography screening and believes that it does save lives. But he agrees that many women wrongly attribute their survival after cancer to early detection as a result of mammography.

"Of all the women who have a screening test who have breast cancer detected, and eventually survive the cancer, the vast majority would have survived anyway," Dr. Begg said. "It only saved the lives of a very small fraction of them."

The notion that screening mammograms aren't helping large numbers of women can be hard for many women and breast cancer advocates to accept. It also raises questions about whether there are better uses for the hundreds of millions of dollars spent on awareness campaigns and the $5 billion spent annually on mammography screening.

One of the reasons screening doesn't make much difference is that advances in breast cancer treatment make it possible to save even many women with more advanced cancers.

"Screening is but one of the tools that we have to reduce the chance of dying of breast cancer," Dr. Esserman said. "The treatments that we have actually make up for a good deal of the benefits of screening."

The Dartmouth analysis comes two years after a government advisory panel's recommendations to scale back mammography screening angered many women and advocacy groups. The panel, the United States Preventive Services Task Force, advised women to delay regular screening until age 50, instead of 40, and to be tested every other year, instead of annually, until age 74. The recommendations mean a woman would undergo just 13 mammograms in her lifetime, rather than the 35 she would experience if she began annual testing at age 40.

But the new recommendations have scared many women who believe skipping an annual mammogram puts them at risk of finding breast cancer too late. But Donald Berry, a biostatistician at M.D. Anderson Cancer Center in Houston, said adding more screening is not going to help more women.

"Most breast cancers are not lethal, however found," Dr. Berry said. "Screening mammograms preferentially find cancers that are slowly growing, and those are the ones that are seldom deadly. Getting something noxious out of the body as soon as possible leads women to think screening saved their lives. That is most unlikely."

Dr. Love, a clinical professor of surgery at the David Geffen School of Medicine at the University of California, Los Angeles, says the scientific understanding of cancer has changed in the years since mammography screening was adopted. As a result, she would like to see less emphasis on screening and more focus on cancer prevention and treatment for the most aggressive cancers, particularly those that affect younger women. Roughly 15 percent to 20 percent of breast cancers are deadly.

"There are still 40,000 women dying every year," Dr. Love said. "Even with screening, the bad cancers are still bad."

Sunday, October 23, 2011

For breast cancer survivors, a long road back to 'normal' -

For Elissa Bantug, one of the scariest moments of her breast cancer treatment was the day it ended.

"I thought finishing treatment was going to be a celebration," says Bantug, 29, who was diagnosed at 23 as a single mother. "When I had radiation after my lumpectomy, I was counting down treatments like a child counting down the number of days of school."

When daily therapy ended, however, Bantug felt cast adrift. For the first time in months, no one would be monitoring her for signs of a relapse. During active treatment, "every day, there was somebody examining me, and every day, the nurses were asking about side effects," Bantug says. "When I asked my oncologist 'When do I see you next?' he said, 'You don't.' He said, 'Have a nice life.'"

Like many cancer survivors, Bantug had questions about staying healthy and recovering from toxic therapies that often leave women infertile. When she returned to her primary-care doctor for advice on preventing a recurrence, "he was really clueless. He said, 'Well, what did your oncologist say?'"

But it was hard to return to normal life, she says. Treatment left her in pain, exhausted, unable to sleep, depressed and anxious; it took 18 months to "really feel whole again."

Two-thirds of cancer survivors have trouble sleeping, even two years after treatment, found a study presented last year at a meeting of the American Society of Clinical Oncology. Up to 30% of breast cancer survivors suffer from persistent fatigue, says Julienne Bower, an associate professor at UCLA. Many also suffer from "chemo brain," a common term for post-cancer memory problems.

"We do a really good job of removing the disease but are not really good at getting people well," says Bantug, who now coordinates the Johns Hopkins Breast Cancer Survivorship Program in Baltimore, part of a national effort to address cancer survivors' long-term needs. The American College of Surgeons now requires accredited hospitals to provide follow-up care plans and make rehab available.

Rhode Island recently announced it will work with a company called Oncology Rehab Partners to provide rehab to patients; it is the first statewide program of its kind.

"It's not OK to just tell patients they have accept a new normal," says Julie Silver, a survivor and assistant professor at Harvard Medical School who started the company. "They should not have to live with more pain and disability than they need to." Patients treated for head and neck cancer may need speech and swallowing therapy, for example, she says.

A 2008 study in the Journal of Clinical Oncology found that 90% of women with metastatic breast cancer could benefit from rehab, but only 30% got it. "Study after study shows that cancer survivors are distressed not because of the diagnosis, but because of their inability to function," Silver says.

And while almost all breast cancer patients would like a care plan, when they are discharged, only 10% received one, found a new survey of 1,000 breast cancer survivors from the Cancer Support Community. Nearly 90% reported a social, physical or emotional issue that posed a moderate to very severe problem. The results show that doctors need to begin screening and monitoring patients for these problems at diagnosis, says Kim Thiboldeaux, the Cancer Support Community's president.

Silver notes that cancer patients have unique needs for rehab. Unlike someone who has a heart atttack and arrives at the hospital near death, cancer patients are often diagnosed when they still feel quite healthy. Treatment, however, can be incapacitating.

"I actually felt great going into treatment," says Silver, who was diagnosed at age 38. After surgery and chemotherapy, Silver says she was in pain and "sicker than I had ever been. I was done, and it was like, 'OK, you're ready to go back to work.' There was no way I was ready to go back to work."
Researchers don't know why such problems are so common. Chemo may cause fatigue by damaging heart muscle or memory problems by killing stem cells in the brain, says Robert Weinberg of MIT.

New research suggests survivors who suffer from fatigue are more likely than others to have immune abnormalities, Bower says. It's possible their immune systems kicked into overdrive during radiation and chemo but never went back to normal.

"Something got out of whack during breast cancer treatment, so their immune system doesn't reregulate," Bower says.

Scientists are studying a variety of possible treatments, from drugs that selectively turn off inflammation, to yoga and tai chi, which may influence the immune system by relieving stress. Cancer survivors who took a four-week yoga class were twice as likely as others to say their sleep improved.

Bantug says she has faced her worst fears about life after cancer. One year after she finished treatment, she found a new lump in her breast and had a double mastectomy.

Yet she calls herself lucky. After chemo, she worried she couldn't have another child; today, she is married and has two girls, one 13, born before cancer, another age 2, born after.

"I feel great," says Bantug, who has begun competing in triathlons. "It took a long time to get here, though."

Saks Institute for Mental Health Law, Policy, and Ethics

The Saks Institute for Mental Health Law, Policy, and Ethics is a think tank founded to foster interdisciplinary and collaborative research among scholars and policymakers around issues of mental illness and mental health. As a research institute, the goal is to study issues at the intersection of law, mental health, and ethics as well as influence policy reform and advocacy actions for improved treatment of people with mental illness. Ultimately, an interdisciplinary approach to these important issues will promote a society of well-rounded persons who work with deep satisfaction and integrity and enjoy a clear mind.

Elyn R. Saks’s Memoir on Schizophrenia Inspires Others -

Researchers have long wondered how some people with schizophrenia can manage their symptoms well enough to build full, successful lives. But such people do not exactly line up to enroll in studies.

For one thing, they are almost always secretive about their diagnosis. For another, volunteering for a study would add yet another burden to their stressful lives.

But that is beginning to change, partly because of the unlikely celebrity of a fellow sufferer. In 2007, after years of weighing the possible risks, Elyn R. Saks, a professor of law at the University of Southern California, published a memoir of her struggle with schizophrenia, "The Center Cannot Hold." It became an overnight sensation in mental health circles and a best seller, and it won Dr. Saks a $500,000 MacArthur Foundation "genius" award.

For psychiatric science, the real payoff was her speaking tour. At mental health conferences here and abroad, Dr. Saks, 56, attracted not only doctors and therapists, but also high-functioning people with the same diagnosis as herself — a fellowship of fans, some of whom have volunteered to participate in studies.

"People in the audience would stand up and self-disclose, or sometimes I would be on a panel with someone" who had a similar experience, Dr. Saks said. She also received scores of e-mails from people who had read the book and wanted to meet for lunch. She told many of them about the possibility of participating in a research project.

She now has two studies going, one in Los Angeles and another in San Diego, tracking the routines and treatment decisions of these extraordinary people. The movie producer Jerry Weintraub has optioned the book.

It has been a remarkable response, considering that the book was almost abandoned. Dr. Saks surveyed friends and colleagues for years before publishing it and got very mixed advice. Her husband was against it; the risks were too high. Academic colleagues warned her that coming out with a disorder as serious as schizophrenia could only harm her. "You want to be known as the schizophrenic with a job?" one said.

Her friend Stephen Behnke, director of ethics at the American Psychological Association, was supportive of her decision. "I remember talking about it just on the cusp of when she was going to send off the manuscript," Dr. Behnke said. "I said that we needed to sit down and make sure she was ready for this. It was like she was about to jump off of a cliff."

Jump she did. With the MacArthur money, she founded the Saks Institute for Mental Health Law, Policy and Ethics to study mental health and society. She is now working on another book, "Mad Women: A Most Uncommon Friendship," with the author Terri Cheney, who has written about her struggles with bipolar disorder.

"I was very lucky, being in academia, where people have been very accepting of this," Dr. Saks said. "Most people struggling to manage a severe mental illness do not have the luxury to do what I did."