Rethinking cancer

For a long time, we thought we knew the drill for battling cancer: Screen regularly to catch it early. Then, if it was operable, root it out. Follow up with chemotherapy and/or radiation to lower the chances of a return.

Though some or all of those tactics are still called for much of the time, the last couple of years have produced a bumper crop of studies telling us that the situation can be more complicated. Sometimes the most aggressive tactics against cancer and other illnesses might be not only unnecessary but downright bad for us.

The debate opened wide with a 2009 recommendation from the Preventive Services Task Force calling for most women younger than 50 to forgo mammograms. Most of the suspicious tissue found during mammograms ultimately is determined to be benign, but finding that out can require biopsies that carry their own risks. In addition, some of the cancers found grow so slowly that they would never present a health problem, yet they are fought with treatments that also carry risks and side effects. Women under the age of 50 are both less likely to have breast cancer than older women and more likely to suffer harm as a result of unnecessary treatment.

The following year, a study published in the New England Journal of Medicine reported that one group of patients with terminal lung cancer lived an average of three months longer than a control group, even though they gave up cancer treatments sooner — perhaps because they also received treatment from the start to reduce pain and discomfort.

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 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 important medical tests and treatments will be withheld for financial rather than health considerations. What many fail to realize is some unnecessary tests and treatments are being ordered for a different financial reason: to earn doctors money. Many procedures are profit centers for medical providers; in other cases, they are to shield practitioners against possible malpractice suits, not 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.

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.

Along with studies on what works best medically, there will have to be research-based determinations of which medical treatments offer too little benefit for the cost. Restrictions on such treatments will be hard for people to accept, but access to health care already is being rationed to some extent by insurance companies, and not always in ways that make medical sense. It will be easier for the public to trust tradition-defying findings if there is no hidden agenda, and it is made clear which recommendations are based on cost-benefit analysis and which are based on research that is concerned only with what ails us and what’s medically good for us.