Friday, May 9, 2014

Universal Mammograms Show We Don’t Understand Risk -

In an effort to reduce childhood injuries, the American Academy of Pediatrics issued a policy statement in 2001 recommending that all kids younger than 2 sit in safety seats in airplanes as they do in cars.

The change meant that families traveling with small children would no longer be able to have them sit on an adult's lap. Instead, parents would need to buy an extra ticket. But the added expense of purchasing a seat for small children would be prohibitive for some traveling families. They might choose to drive instead, which is a real problem, because driving is far more unsafe than flying.

It turned out that if just 5 percent of families chose to make an additional 400-mile road trip because of this policy, then the number of children killed each year would increase. The policy would also be enormously expensive.

Try relating this story to people, and you quickly learn that instinct often trumps data. They just know, deep in their hearts, that flying is scary and dangerous. They just believe that driving is safer. Convincing them otherwise is nearly impossible.

People are often terrible at understanding risk. These misunderstandings make creating health policy much more difficult. They also make reducing health care spending very hard.

Recently, a manuscript in the New England Journal of Medicine described the disconnect between women's beliefs about their risks from breast cancer and the actual risks. Out of any group of 1,000 50-year-old women today, about five are likely to die of breast cancer in the next 10 years. If all 1,000 women received mammograms at age 50 and every two years for the next decade, though, the number of deaths might decline by only one — to four, the collected research shows.

But if you ask women about the risks of breast cancer and the benefits of universal screening, as researchers did in a study, the answers are very different. On average, respondents said that more than 160 out of every 1,000 would die without screening. With screening, the number of deaths would drop in half, to about 80.

Even without a universal screening mammogram program, the actual likelihood of a 50-year-old woman dying of breast cancer in the next 10 years is one half of one percent. And adding a screening program has only a marginal effect on that risk. Diagnostic methods these days catch most cases of breast cancer that can be effectively treated, and much of what is picked up by universal screening is over-diagnosis.

Men, of course, suffer from these same biases. I could easily have substituted the above story with one on prostate-cancer screening, and the gist would be the same.

Whenever I discuss data like these, I am inundated with angry emails telling me that mammograms or prostate-cancer screening saved a loved one's life. Or I'm presented by outright denials that the data I'm describing are true. People just know that breast cancer and prostate cancer will kill people, and that screening will save them.

Why is all of this important? Because we have a limited amount of money to spend on health care each year. Money we spend on things that don't work is money we can't spend on things that do. The Affordable Care Act has, within it, language that specifically "protects" mammogram coverage. Screening must be paid for, even if we find that universal screening doesn't work or results in harm.

Screening programs are expensive. Screening mammograms probably cost us more than $7.8 billion a year, which is equal to more than 25 percent of the National Institutes of Health budget for research. The true cost of screening is even higher, because it leads to over-diagnosis of breast cancer, and treatments that don't improve health.

Even if you believe, as many do, that the United States spends too little on women's health, and that taking money away from breast cancer is wrong, wouldn't this money be better spent paying for treatment of confirmed cases, for research into new drugs, or even for support for women who are undergoing treatment? Wouldn't those steps improve the lives of more women than universal screening?

We can't make these kinds of changes, though, while we allow beliefs to trump facts. Study after study, and our reaction to them, show that our perceptions don't line up with reality. If we want to live longer, healthier, and, most importantly, better lives, it's worth fighting some of those assumptions.

Thursday, May 8, 2014

Cancer Doctor Peter Bach on Losing His Wife to Cancer -- New York Magazine

The streetlights in Buenos Aires are considerably dimmer than they are in New York, one of the many things I learned during my family's six-month stay in Argentina. The front windshield of the rental car, aged and covered in the city's grime, further obscured what little light came through. When we stopped at the first red light after leaving the hospital, I broke two of my most important marital promises. I started acting like my wife's doctor, and I lied to her.

I had just taken the PET scan, the diagnostic X-ray test, out of its manila envelope. Raising the films up even to the low light overhead was enough for me to see what was happening inside her body. But when we drove on, I said, "I can't tell; I can't get my orientation. We have to wait to hear from your oncologist back home." I'm a lung doctor, not an expert in these films, I feigned. But I had seen in an instant that the cancer had spread.

PET scans are like that, radioactive tracers that travel around the body and measure how much work different cells are doing. And cancer cells are very active workers. The scans are like the ground seen from the air at night. When there is no cancer they look like Idaho, all quiet. Really bad news looks like downtown Chicago or Phoenix.

It was a warm night for early June, the beginning of the winter in Argentina. People crowded the sidewalks, returning from work, stopping for dinner. All the everyday stuff that fills our lives, neither adding particular meaning or taking it away. We pulled into the garage with the narrow entrance; our tires squeaked on the newly painted floor. Ruth was silent. I was silent. I knew. She didn't.

Actually, she probably did.

My wife was dead eight months later. We were back in New York. In our home. During our winter.

It didn't take long for those films to be examined and interpreted by doctors at Memorial Sloan Kettering Cancer Center, the hospital where I've been a doctor for more than a decade and where Ruth had been treated when she was first diagnosed with breast cancer, three years earlier, in 2008. Only a few minutes after we parked the car, the phone in our apartment rang. It was the oncologist.

Ruth and I sat next to each other on the couch, each with a handset. The oncologist used many words familiar to me—metastasis, emergency radiation, focusing on "quality of life," not cure. Technical jargon sneaked into my questions as Ruth's name disappeared from them. "Could she develop cord compression?" I asked. Then her voice. "What's that?"

Ruth's doctor never made us wait. No gentle approach, no layer of euphemism obscuring the truth, no gingerly poke and quick retreat from the scary thing over there. He filled in answers to unspoken questions. "There's a lot we can do." "This is manageable." "You might have many years." But then circling back. "It can't be cured anymore. Our goal now is to slow down the cancer and give you as much quality life as we can." To paraphrase, the films meant Ruth was going to die.

When I relayed that conversation to my friends, many of whom are cancer doctors, they were pretty surprised. What Ruth's doctor had done was unusual, or maybe even inappropriate, they told me—delivering bad news, especially over the phone, before it needed to be conveyed. When I asked them when the right time was to tell someone that death is unavoidable, they most often told me that the moment occurs after several successive attempts at stopping the cancer have failed. Only then, when the patient is cornered by cancer, that's the time.

Doctors claim that patients aren't ready for the bad news earlier, when they are still digesting their shocking predicament: that their lives have changed irretrievably; that their priorities, their future aspirations, their promises to their loved ones—both the explicit and, more important, the implicit ones—would go unfulfilled. They cite their own hesitations too. Doctors want to be purveyors of hope rather than despair, a motive sometimes attributed to compassion, sometimes to a starker concern that patients will find a new, more optimistic second opinion.

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