If America ever hopes to get some control over the soaring cost of our health care system and at the same time improve quality, we need to question our present health care practices. Medical procedures, testing, and treatments need to be based on sound science and not on pressures from economic forces, advocacy groups, or malpractice concerns. Those pressures, which influence all medical decisions in America, contribute to the high cost and suboptimal quality which plagues American medicine. Several articles recently published in major journals, the New England Journal of Medicine (NEJM) and the Annals of Internal Medicine (AIM), cast doubt, for example, on widely practiced cancer screening tests.
In the AIM on 1/6/09 the results of a very large case control study from Ontario, Canada were published which looked at the effect of screening colonoscopy in preventing death from colorectal cancer. The gold standard for a study of this sort is a randomized controlled trial in which subjects are randomly assigned either to receive a colonoscopy or not to receive one and then followed prospectively for years to see if the intervention affected their likelihood of dying from colon cancer. No such study has yet been done for colon cancer. A case control study is the next best type of research and looks back retrospectively at people who have had colonoscopy to determine if having the procedure decreased the possibility of colorectal cancer death.
In the AIM study, the mortality from colorectal cancer decreased 33% in those screened. A nice benefit all right, but probably disappointing to those colonoscopy advocates who might have hoped that inspecting the lining of the colon would eliminate almost all colorectal cancer deaths. What was most disappointing to those advocates, though, was that the study showed no benefit at all in preventing death from right-sided colon cancer death. (The right side of the colon is that part that is most distant from the anus.) The only part of the bowel in which colonoscopy was effective in preventing cancer death was in the distal colon, that part closest to the anus. Cancer death in this part of the colon has already been shown to be prevented similarly by a procedure called a flexible sigmoidoscopy, an easier, less invasive, and less costly procedure that uses a shorter tube than a colonoscope. It should not be forgotten that very serious complications could occur with colonoscopies in about 2 out 1000 people including heart attacks and even death. Our national policy of blanket colonoscopies -- promoted by specialty organizations, advocacy groups, consumer demand, and fear of malpractice -- could be replaced, according to this study, by an easier, safer, less expensive yet equally effective screening test.
Two reports printed in the 3/26/09 NEJM similarly challenged another screening test routinely performed in America. These long-awaited studies, the Prostate, Lung, Colorectal Cancer, and Ovarian Cancer Screening Trial (PLCO) and the European Randomized Study of Screening for Prostate Cancer published their findings on the effect of PSA screening on preventing death from prostate cancer. Both were very large studies involving tens of thousands of men and lasting 7-10 years. The PLCO showed no benefit at all with PSA testing in preventing prostate cancer death whereas the European Study demonstrated a 20 % reduction in those screened. Even in the European Study, though, over 1400 men needed to be screened, hundreds of biopsies needed to be done, and 48 men treated with major surgery and/or radiation to prevent one cancer death. It is unclear what the medical impact of this demanding testing and treatment was on the men. Neither study was able to answer the pivotal question: does PSA testing overall produce more harm or more benefit? Based on evidence like these studies, the US Preventive Services Task Force does not recommend routine PSA screening for men. Yet in America today men expect and demand PSA testing and for a physician not to recommend routine PSA testing is a certain invitation for a malpractice suit if that man subsequently develops prostate cancer.
It is doubtful whether these studies or similar ones will have any major impact on colorectal cancer and PSA testing as practiced in the U.S. Economic forces, consumer demand, and avoidance of malpractice suits so dominant our health care policies that science has lost is importance. It is no wonder that we spend twice as much on health care as the other developed countries yet our medical system is ranked 37th by the World Health Organization. Until we develop medical policies based on scientific accountability we are condemned to suffer with a permanent cost-quality disconnect in medicine.