Saturday, January 17, 2015

Screening for hepatitis C and lung cancer: proceed with caution

Most of my patients don't know (or if they know, don't particularly care) that I blog, but after practicing for nearly three years at the same Washington, DC practice, I am starting to see a few who specifically chose me to be their doctor because of something I wrote in Common Sense Family Doctor or my health care philosophy of "conservative medicine." It isn't that I am averse to doing screening tests; for example, I still order PSA tests for men and mammograms for women in their 40s, provided that they have been informed of the likely harms as well as the possible benefits. What I can't abide are physicians who bully patients into having these tests, or in the case of prostate cancer screening, order the test without even bothering to tell them.

Speaking of screening tests, my first video commentary for Medscape Family Medicine addressed the key issues that primary care physicians will need to review with patients eligible for CT lung cancer screening. Recognizing that the decision to screen or not screen will be a close call for many, the Centers for Medicare & Medicaid Services plans to pay physicians to have a discussion about pros and cons. Although I am concerned that these discussions may not happen, I hope that my commentary makes a difference. Non-clinicians who don't have access to Medscape can read about the issues in one of my previous blog posts.

This week also saw the publication of the analysis, "Is widespread screening for hepatitis C justified?" that I co-authored in BMJ with Ron Koretz, John Ioannidis, and Jeanne Lenzer. In this paper, we argued that the rush to expand screening to all persons born between 1945 and 1965 (the "Baby Boomer" generation) regardless of health status or risk factors could do more harm than good because 80 percent of people with chronic hepatitis C do not develop liver complications and, therefore, cannot benefit from treatment; and the surrogate marker ("sustained viral response" after 12 weeks) that persuaded the U.S. Food and Drug Administration to approve the fantastically expensive new drugs may correlate imperfectly with the health outcomes that patients really care about:

Given the uncertainty about the validity of the surrogate markers, the lack of evidence regarding clinical outcomes of treatment or of screening strategies, and the adverse events caused by the newer regimens, screening may be premature. ... Given the converging recommendations from major organisations for widespread screening, the pressure on practitioners to adopt this policy is mounting. We have a limited window of opportunity to collect appropriate evidence on whether this is a good idea. Until then, physicians should not be pressured to enforce birth cohort screening strategies out of enthusiasm for new treatments that have not yet been shown to cause long term clinical improvement.

For additional context, or if you prefer listening to reading, Jeanne and I recorded a 15-minute podcast to accompany the article which nicely summarized these arguments.