VIDEO: The Truth about Mammograms - Adam Ruins Everything

Here's a great, brief explainer about the problems with mammography (and most cancer screening)  - 2:43

A slightly longer/better version is here on TruTV's website: The Truth About Mammograms - Full Episode (4:30)

Source: http://www.trutv.com/shows/adam-ruins-ever...

FACTS & MYTHS: Prevent and Treat Cancer with Diet and Lifestyle

Families, doctors, nurses, patients, people all:

Everyone knows someone with cancer. Cancer is unfortunately inevitable unless something else gets you first. It may sound awful to talk that way but because of what cancer is - essentially the unchecked growth of progressively more abnormal cells - and the fact that our cell's replicating machinery gets a little wonky as it wears out over time, the older we are the more likely we are to develop cancers.

Cancer is horrible. It devastates happiness, bodies, minds, families, plans, and dreams. We want to do everything possible to treat it and prevent it. Although I've written a lot about the futility of aggressive care in the end of life, the harms of delaying a palliative approach, and our misplaced trust in screening (which often harms more than it helps: PSAs or mammograms, for example), I also advocate strongly for patient access to the things that do work.

There are things you can do to lower your risks, robustly backed by the evidence: 

  • Avoid smoking
  • Exercise regularly
  • Stay away from environmental/industrial carcinogens like asbestos, radon, and benzene
  • Reduce radiation exposure by avoiding unnecessary medical imaging tests
  • Avoid excesses of alcohol
  • Wear sunscreen
  • Consider a pap test
  • Only take supplemental hormones if medically required
  • Get other 'screening' tests eg. colonscopy if you are a high-risk patient (eg. an immediate relation was diagnosed with colon cancer)

There is a great summary of some specific examples of dietary items in the "Summary of global evidence on cancer prevention" from the World Cancer Research Fund International.

As much as we want them to work, natural supplements, diets, 'miracle' clinics overseas, and homeopathy just don't.

Billions of dollars are made in scaring people into taking 'natural' remedies that are meant to prevent or treat cancer. Let me tell you: if these remedies were effective, they would be patented, put into pill form, and your family physician would be nagging you to take them. Heck, we might even lobby the government to put cancer-preventing agents in the drinking water! And if there was such thing as a miracle clinic, curing cancer constantly, well I would like to work there because that sounds amazingly rewarding.

Sadly, despite our dearest hopes, turmeric and elimination diets, cannabis oil, black fungus like that growing at Chernobyl (Fox News), and a whole host of other things continue to be proven useless at preventing or treating cancer. Most of these 'remedies' are harmless, but some have real side effects and none of them help the wallet.

In fact, while people are wasting their time, money, and hope on these snake oils, they are depriving themselves of the opportunity to focus on what matters:

  • Eating whatever you want
    • to try to slow the process of weight loss from cancer and to enjoy life because food = joy for many
  • Using money to enjoy experiences that are important to you 
    • visiting family, ticking items off the bucket list... one incredible patient I met shocked his family and had an incredible time by skydiving for the first time after age 70 (despite cancer with metastases to bone!)
  • Focusing on treatments that have been shown to be effective through scientific study
    • nothing breaks a caregiver's heart more than seeing someone chose an 'alternative' treatment when there is a validated one that would likely be well tolerated, and is quite likely to lead to cure (eg. death of Makalya Sault, after her family got their hopes ensnared by a quack in Florida
  • Working through the difficult task of coming to terms with having cancer, whether treatable or not
  • Receiving palliative care (which improves quality of life and can actually extend life!)

Optimism is not wrong - optimistic people probably live longer. If you trust that (scientific) statement, then you should also trust that the optimism should be directed towards scientifically-backed things that work.

--

Learn more about Tackling cancer treatment myths, from clean eating to cannabis

Source: https://www.theguardian.com/science/blog/2...

Mammogram Theater: A Visual Aid For Medical Decision-Making

With a title like "mammogram theatre" you would wonder if this post is meant to poke fun at the elaborate song and dance of mammography; we have spent years promising women that "early detection is key," only to realize that screening mammography cannot do what we originally hoped it could (but many still pretend it can).

Of course women want their breasts and lives saved. But the information on the benefits of mammography has been largely overstated in part due to cognitive biases (like lead-time bias, base-rate fallacy, etc), and the risks are too often left out of the conversation.

Every test has risk and benefits, but it can be challenging to decide if a test or treatment is right for you or your patient when there is too much information, experts disagree when they review the same studies, and the media has a constant see-saw back and forth of "yes" and "no" headlines that seem only to confuse. It can feel a bit like ping-pong, following the discussion back and forth. It's not really fair to ask patients to make sense of all this.

So yes, the promise of benefit of mammography may have been a bit of dramatization, but the theatre I speak of is a literal one. 

Dr. Andrew Lazris is an American internist who partnered with environmental scientist Erik Rifkin to popularize a simple, easy way of showing how many are helped and harmed by common tests and procedures.

Lazris and Rifkin have developed a tool to give people a realistic way of evaluating 'hope and worry;'

Their "benefit-risk characterization theater" images vividly show the odds, based on solid research. (read more on NPR)

This is a tool to help doctors and patients have informed discussions about the risks and benefits of breast cancer screening with mammography, to engage in shared-decision making on the topic. Take a look:

This tool has been added to the "hands-on tools" section of this website, where you can find other tools like it.

Source: http://www.npr.org/sections/health-shots/2...

Why Survival Rate Is Not the Best Way to Judge Cancer Spending

The New York Times has a great piece on their Upshot blog about assessing value when it comes to testing and treating cancer. It can be very challenging to measure whether the money we spend on health care is providing good return, making a meaningful improvement for patients.

We want every dollar we spend to help people live longer and higher-quality lives. However, when data of survival rate is examined, it may lead to inaccurate conclusions about the effectiveness and worth of a test or treatment.

The Upshot expands upon Why Survival Rate Is Not the Best Way to Judge Cancer Spending. Dr Carroll explains how statistics - particularly the parameter of 'survival rates' - can mislead us into thinking we are helping patients, but because of lead-time bias and overdiagnosis bias, what we are measuring as "success" is not actually translating into improvement for the patient. Our mis-guided spending is leading to the point where we do not have money to spend on more impactful interventions. 

Read the article for clear explanations of these biases with illustrative examples, and consider that by focussing on the wrong measures, "we may be getting far less for our money then we think."

Source: http://www.nytimes.com/2015/04/14/upshot/w...

Better informed women probably less likely to choose mammography

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An interesting article was published in the latest Lancet: Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial.

In brief, women who got information about the risk and possible harms of breast cancer screening (by mammography) were less likely to intend to be screened. The study didn't go on to look at what the women actually chose (only what they intended to choose). However, it still confidently suggests that women who have all of the information are less likely to get screened.

Contrast this informed approach with the classic approach from the well-intentioned doctor: "You need a mammogram to screen for breast cancer. Here is the requisition."

It is not wrong to say no. (These are the words of Dr Iona Heath - well ahead of the curve - in the title of a  BMJ paper in 2009 regarding this same topic).

It is not wrong to say no. And the more you know, the more likely you'll say no. 
 

Not sure what to do for yourself?
Not sure how to start discussing this with patients?
 

- Here is a Canadian resource to help you decide if Mammography is right for you; it's not perfect but it is a start

- Below is an icon array from the Harding Center for Risk Literacy that helps visually represent the benefits vs. harms of mammography:


Source: http://www.thelancet.com/journals/lancet/a...

Demanding Patients? Not so in Oncology

Surveyed physicians tend to place responsibility for high medical costs more on “demanding patients” than themselves. However, there are few data about the frequency of demanding patients, clinical appropriateness of their demands, and clinicians’ compliance with them.

Exactly. This JAMA Oncology paper looked at 5050 patient-provider encounters in the oncology context and found that patients requested things in 8.7% of the encounters, and these demands were only considered inappropriate in 1% of encounters.

Number and Types of Patient Requests or Demands (JAMA Onc)

Number and Types of Patient Requests or Demands (JAMA Onc)

I think we need to be very careful about blaming patients. I do it... but I'm getting better at seeing the bigger picture. Yes, sometimes they are in the stage of denial and struggling to cope with their diagnosis. They may ask for completely inappropriate tests or treatments. Sometimes their expectations are absolutely ridiculous but most of the time this is not the case. The patient is not crazy or 'demanding.' A lot of the time it is we clinicians who put some of the more unrealistic expectations on people's radar.

Educating patients wouldn't change this, except if we can encourage them à la Choosing Wisely to initiate discussions with their physicians about unnecessary tests and treatments.  Educating the clinician, particularly encouraging transparency and openness in communication is really important. However, the biggest thing we can do is to change the overall culture of the health 'system' and our society to make it "okay" to talk about these issues frankly.

I work quite frequently with oncology patients, often in a supportive or palliative role. I find it shocking that many of them have never discussed dying, have not made advanced care plans, and do not understand the goals of their treatment. Often a patient is receiving palliative therapy and yet they believe it is a curative therapy. They may demand aggressive medical treatment, not realizing that they are very close to dying.

Sometimes, when I liaise with the oncologist, he or she explains that they had frank discussions about these things, and I can see it in the notes. It's just been hard to accept and people don't really hear what has been said. Other times, "it just never came up." I find that that hard to believe. It should come up. Shouldn't it?

Not talking about the end of life is doing a patient a disserviceHow can they make decisions about their care without knowing what is going on? It also suggests - as made clear by this study -  that inappropriate interventions might be coming from the clinician, not necessarily initiated at the behest of the patient.

What do you think?

Source: http://oncology.jamanetwork.com/article.as...

Does screening for disease save lives in asymptomatic adults? NO

I remember learning in medical school about what a screening test is and the factors necessary to make a 'good' screening test.

The disease in question should:
- constitute a significant public health problem, meaning that it is a common condition with significant morbidity and mortality.
- have a readily available treatment with a potential for cure that increases with early detection.
The test for the disease must:
- be capable of detecting a high proportion of disease in its preclinical state
- be safe to administer
- be reasonable in cost
- lead to demonstrated improved health outcomes
- be widely available, as must the interventions that follow a positive result 

(American Medical Association Council on Scientific Affairs. Commercialized Medical Screening (Report A-03). no longer available online, but cited on Virtual Mentor)

We have obviously lost our way!!

In medical school I was excited about ensuring every patient got ALL THE SCREENING! I never thought I'd struggle to justify a screening test. 

These days, I would be hard-pressed today to confidently name you one "good" screening test. Maybe paps? Maybe colonoscopies? I follow my jurisdiction's guidelines. I discuss the risks and benefits of screening with patients because I'm not certain that what we are doing is definitely "good."

It's hard to summarize it any more clearly than this:

Among currently available screening tests for diseases where death is a common outcome, reductions in disease-specific mortality are uncommon and reductions in all-cause mortality are very rare or non-existent.

A paper in the International Journal of Epidemiology from June 2014 that just came to my attention recently draws this conclusion.

The authors looked at data from 48 Randomized Controlled Trials (RCTs) and 9 meta-analysis on the subject of screening tests (39 of them) for 19 potentially deadly diseases. The studies they included regarded things like mammography for breast cancer, echocardiography for heart disease, PSAs for prostate cancer, and so on.

Some limitations are acknowledged but I also wonder if there is another. For very worthwhile "common sense" things (if these things exist, and I'm not saying they do!) there is little published data. For example, the efficacy of the newborn screening exam or GBS screening in pregnancy don't seem to have been thoroughly studied but are considered to be "law, written in stone" in practice. For the more controversial screening tests, there are more trials published, and so that might weight this meta-analysis towards saying that screening tests on the whole are not useful. I actually think the conclusion the their analysis is appropriate, as the closer we look at other "written in stone" practices, the more we realize we were wrong!

This sentence in the discussion of the article I think sums up the complex nature of the results really well:

There are many potential underlying reasons for the overall poor performance of screening in reducing mortality: the screening test may lack sufficient sensitivity and specificity to capture the disease early in its process; there are no markedly effective treatment options for the disease; treatments are available but the risk-benefit ratio of the whole screening and treatment process is unfavourable; or competing causes of death do not allow us to see a net benefit. Often, these reasons may coexist. Whether screening saves lives can only be reliably proven with RCTs.

See for yourself! Read the full article.

 

Patient Story: Adventures in Choosing Wisely

Here's an awesome example of a patient who worked with her doctors to Choose Wisely.


Amy Berman has breast cancer that has metastasized to bone. She is a Registered Nurse (RN), a Senior Program Officer at the Hartford Foundation, and a vocal advocate for patient-centred care.

She decided with her doctors that she would benefit most from treatment with a single fraction of palliative radiotherapy instead of an extended course. The goal of this being some relief from the pain that stemmed from the new area of cancer on her ribs.

Her choice is in keeping with the evidence and recommendations of the Choosing Wisely items in Radiation Oncology. In the USA, the guidelines developed by The American Society for Radiation Oncology (ASTRO) suggest:

  • "Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases." 

 The Canadian Association of Radiation Oncology, in their version of recommendations, suggest:

  • "Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis."

Further, they explain: "Randomized trials have established that single-fraction radiation to a previously unirradiated, uncomplicated peripheral bone or vertebral metastasis provides comparable pain relief and morbidity compared to multiple-fraction regimens, while optimizing patient and caregiver convenience. Although it results in a higher incidence of retreatment at a later date (20% vs. 8 % for multi-fraction regimens), the decreased patient burden usually outweighs any considerations of long-term effectiveness for those with a limited life expectancy."

Arranging this appropriate treatment was harder for Amy (and her doctor) than just making the choice. See her blog post to find out more, as there was more to the story! It appears that not everyone is on board with Choosing Wisely, yet  . . .

Source: http://www.jhartfound.org/blog/adventures-...

How can you have an overdiagnosis of cancer? Either it's there, or it's not.

"How can you have an overdiagnosis of #cancer?  Either it's there, or it's not." – @susila55

[click to expand]

Rates of new diagnosis and death for five types of cancer in the US, 1975-2005. Adapted from Welch and Black, in Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012; 344:e3502

In response to tweets about a potential for overdiagnosis in thyroid cancer cases, a twitter user, Susan Burke Mangano (@susila55), asked this question.

There have been many articles lately on overdiagnosis of almost all kinds of cancer. Our twitter discussion was mainly around thyroid cancer (with Dr Gilbert Welch leading in publications eg. Current Thyroid Cancer Trends in the United States).

Whether breast or prostate, thyroid or renal, the conclusions are generally the same: we are diagnosing more and more cancer, but it is not affecting mortality rates.

How? What?

"There is an ongoing epidemic of thyroid cancer in the United States. The epidemiology of the increased incidence, however, suggests that it is not an epidemic of disease but rather an epidemic of diagnosis." – Welch et al.

I'm not going to explain it here myself since it has already been done well in many places, the most straightforward of which is this video/article combo, by the Wall Street Journal.

I highly recommend you take a look.

Read Some Cancer Experts See 'Overdiagnosis,' Question Emphasis on Early Detection in the Wall Street Journal.

 

* As they have just locked this article (you need a WSJ subscription or institutional access eg. university library account), I will include a few pertinent quotes here:

 

While it's clear that early-stage cancers are more treatable than late-stage ones, some leading cancer experts say that zealous screening and advanced diagnostic tools are finding ever-smaller abnormalities in prostate, breast, thyroid and other tissues. Many are being labeled cancer or precancer and treated aggressively, even though they may never have caused harm . . .
"We're not finding enough of the really lethal cancers, and we're finding too many of the slow-moving ones that probably don't need to be found," says Laura Esserman, a breast-cancer surgeon at the University of California, San Francisco. . . .
"Unfortunately, when patients hear the word cancer, most assume they have a disease that will progress, metastasize and cause death," the group wrote in the journal Lancet Oncology in May. "Many physicians think so as well, and act or advise their patients accordingly." . . .
Overdiagnosis--the detection of tumors that aren't likely to cause harm--is now a hot topic in other cancers as well. A growing volume of studies estimate that as many as 30% of invasive breast cancers, 18% of lung cancers and 90% of papillary thyroid cancers may not pose a lethal threat. . . .
"Everyone says they'd be willing to be overtreated if it means not dying--but that's a big fallacy," says Dr. Esserman. "By treating 1,000 people who have low-risk disease, we're not going to save the one person with aggressive disease." . . .
Says Dr. Esserman: "We need to start testing some of these ideas, rather than just fighting over them. People are afraid to do less. We want to figure out how to do less safely."
- Melinda Beck, WSJ

Simple tool illustrates risks/benefits of prostate cancer screening

Struggling with what to do as far as prostate cancer screening?

The Harding Center for Risk Literacy has some very helpful illustrative "Fact Boxes" that share the evidence behind Digital Rectal Exams (DREs) and Prostate Specific Antigen (PSA) tests.

See the "Risks and benefits of prostate cancer screening" on their site.

Of course, these shared decision-making (SDM) aids only take into account the Cochrane Review, but this is a systematic meta-analysis and so I think quite powerful data.

To see a bit more background, but a similar conclusion, view this review in the Journal of Family Practice. They suggest:

Do not routinely screen all men over the age of 50 for prostate cancer with the prostate-specific antigen (PSA) test. Consider screening men younger than 75 with no cardiovascular or cancer risk factors—the only patient population for whom PSA testing appears to provide even a small benefit.

Family medicine literature seems to be consistent with the above, though our practice lags behind. Many of my urologist colleagues shake their head and insist that we offer screening PSAs, but I'm beginning to feel it just doesn't add up to "good care."


What do you think? Would you get screened? Would you encourage your patients to be screened?

If you are looking for more decision-making aids, check out the Hands On part of the Tools section on this site.