Rethinking cancer

New studies show that aggressive measures aren’t always best. What does this mean for healthcare?

This year, several more such studies have been released. In the spring, the preventive services task force was back with a recommendation that a common test for prostate cancer be abandoned because the chances that men would be harmed by unnecessary treatment far outweighed the chance that their lives would be saved. And nine medical specialty panels came out with a sweeping recommendation for doctors to order 45 common tests, medications and procedures less often for cancer and a wide range of other illnesses, saying they were often unnecessary and potentially harmful. Those include antibiotics for uncomplicated common sinus infections and routine EKGs for patients who have no symptoms of heart trouble.

Most recently, a study published this month in the New England Journal of Medicine found that men whose early-stage prostate cancer is carefully monitored but not treated right away appear to live as long as men whose cancer is immediately operated on, and that they also avoid the troubling side effects of urinary problems and erectile dysfunction. The study isn’t definitive, and its findings might not apply to all forms of prostate cancer or to younger men.

The public, though, seems a little doubtful about pronouncements that Americans are over-tested and over-treated, and it’s easy to see why. Our very nature tells us that if there’s a bad thing in us like cancer, we want it out. Also, insurance companies and the government have been warning that runaway increases in medical costs are unsustainable. This makes patients worry that important medical tests and treatments will be withheld for financial rather than health considerations. What many people fail to realize is that some unnecessary tests and treatments are currently being ordered for a different financial reason: in order to earn doctors money. Many procedures are profit centers for medical providers; in other cases, they are ordered to shield practitioners against possible malpractice suits, rather than because they are medically necessary and appropriate.

The sensitive new technologies that enable doctors to find and diagnose more medical problems have also led them to find, explore and treat things that never would have caused problems, according to Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. “We now recognize that we all harbor abnormalities,” Welch said in a Times story last year.

That’s not to say that the nation should instantly start following all of these findings and recommendations all of the time. In some cases, more research is needed. And in any specific patient’s case, physicians should make decisions based on the individual’s needs and situation; the task force, for example, never meant to say that a 45-year-old woman with a strong family history of breast cancer should avoid mammograms. But increasingly, the nation’s medical establishment is coming to recognize that aggressive treatment can sometimes be as much a problem as certain diseases.

This will be an easier pill for patients to swallow if researchers and policymakers do their best to clarify which issues are financial and which are medical. The studies on palliative care and on surgery for early-stage prostate cancer, for example, clearly fall into the latter category. They didn’t even consider the cost factor of surgery or of efforts to extend life in the late stages of terminal lung cancer. Rather, they were designed to determine what brought about the best results for patients.

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