As the chief medical officer of the American Cancer Society, Dr. Otis Brawley should know whereof he speaks when it comes to the state of cancer care in America. He pulls no punches in his new book, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America. With its publication, he is taking aim at not only doctors but also patients: http://www.usatoday.com/news/health/story/health/story/2012-01-30/Doctor-exposes-the-dangers-of-overtreatment/52893278/1. Do you agree with the following?
CANCER SCREENING: Dr. Brawley has historically been outspoken about the hazards of ”overdiagnosis” with tests for cancer screening: http://www.usnews.com/opinion/articles/2009/12/01/benefits-of-psa-test-are-exaggerated . The classic example is the PSA test for prostate cancer. The argument against widespread routine PSA testing is that many men “die WITH prostate cancer rather than OF it.” In other words, a huge portion of men who receive the PSA blood test, are found to have a high level, undergo biopsy, and are diagnosed with prostate cancer would have died of other causes. In effect, they are subjected to testing, potential anxiety, an invasive biopsy, & possible treatment (surgery, external radiation, brachytherapy seeds, etc), none of which improves their overall survival. While a massive European randomized trial showed a survival benefit to men who received PSA screening (http://www.nejm.org/doi/full/10.1056/NEJMoa0810084), another large American study did not ( http://www.nejm.org/doi/full/10.1056/NEJMoa0810696). Even most vocal advocates in favor of the PSA test admit that overdiagnosis remains a major problem, at least in the U.S.
CANCER TREATMENT: The current model of medical care in the U.S. is predominantly “fee for service.” For any given type of disease, including cancer, more testing and more treatment generally results (for the medically insured) in greater financial rewards for the hospital and/or treating doctor(s). Dr. Brawley provides the example of a well-insured patient whose private medical oncologist treats him with chemotherapy that is non-standard for the sole purpose of making more money: http://well.blogs.nytimes.com/2012/04/20/how-doctors-and-patients-do-harm/. While oncologists and other physicians are not immune to the lure of the almighty dollar, in my experience greedy physicians have been the exception more than the rule. Clearly though, the “fee for service” model for cancer treatment specifically and medical care generally is not one that is viable if our nation is to achieve “affordable healthcare for all.” Most doctors will be hurt financially by any movement away from “fee for service.” However, I personally believe that move must occur in order to achieve the greatest good for the greatest number in a financially responsible way. My fear for my colleagues in medicine is that doctors and other healthcare providers will shoulder a greater financial burden than the other key players in our currently dysfunctional system. Given their tremendous political clout and power, I doubt that the largest private insurance companies will suffer significant financial losses.
SHARED RESPONSIBILITY: Doctors and hospitals treat patients. Insurance companies and the U.S. government (Medicare, Medicaid) pay for most of the care. Lawyers make the law (and have been known to sue doctors that don’t order the right test or use the right treatment). All share responsibility for the current dysfunctional state of the medical nation. However, it should come as no surprise (although it will) to most Americans that patients are as much to blame as doctors and these other groups. On this point, I am largely in agreement with Otis Brawley. We want the best and we want it now. We assume that more is better. If we are not paying for it (whether uninsured or insured with a deductible that has already been met), then we freely say “order whatever tests you need, doc!” Sadly, I have no easy answers in this regard. Reigning in expectations is challenging, particularly when the personal benefits to the individual are not immediately tangible. As a society, we have apparently not yet heard a compelling argument for change. I look forward to reading the rest of Dr. Brawley’s book for his thoughts on the subject.
- Patrick Maguire MD (thecancermd.com)
My exception to Dr. Maguires comments is that Dr. Brawley should know all there is about cancer. What is discerning is that Dr. Brawley, an African American for whom prostate cancer is more apt to be diagnosed and often in advanced stage, refuses to have his PSA level tested. I’m not sure if he also refuses the DRE. Though there may be “huge” numbers of men diagnosed that don’t require immediate treatment, my concern is for that significant number (over 30,000 men dying of prostate cancer annually) who did not have annual screening with PSA and/or DRE until their cancer was too advanced to be eradicated or even reined in until they “died of other causes.” Way too many of these men experienced extremely painful and dibilitating issues as their bodies wasted away from the effects of their prostate cancer. Better to be aware of the presence of developing prostate cancer than to ignore that development. The pressure must be on diagnosing physicians to encourage Active Surveillance with close monitoring when diagnostics indicate the cancer is in very early development; not to just do away with annual prostate cancer screening and let those with more developed prostate cancer die of this insidious men’s disease.