PSA screening by the numbers: no benefits, many harms

Previous studies found that two-thirds of men who receive prostate-specific antigen (PSA) screening for prostate cancer didn't have shared decision making with their physicians. If shared decision making occurred at all, patients were more likely to remember hearing about the advantages than the disadvantages of PSA screening, and many older men with a high probability of death within the next 9 years were screened nonetheless.

These findings, along with a Cochrane review and another systematic review (that I co-authored) which both found no pooled mortality benefits in several randomized controlled trials, led the U.S. Preventive Services Task Force to recommend against PSA-based screening for prostate cancer in 2012. Since then, the American Academy of Family Physicians and the American College of Preventive Medicine have added this service to their Choosing Wisely lists of tests and procedures that patients and physicians should question.

The Medicine By the Numbers published in the May 1st issue of American Family Physician clearly illustrates that the harms of PSA screening exceed the benefits. 1 in 5 men who received PSA screening ended up undergoing a biopsy for a false-positive test; 1 in 34 and 1 in 56 screened men, respectively, suffered erectile dysfunction or urinary incontinence as a result of prostate cancer treatment. In contrast, PSA screening prevented zero deaths from prostate cancer or all causes. In other words, no benefits.

This review begs the question of why clinicians should bother with shared decision making in most average-risk men, rather than simply telling them that this test is a bad deal.

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This post first appeared on the AFP Community Blog.

Everything but the kitchen sink in public health

The buzzwords many use in medicine today are "personalized," "individualized," or "targeted." Rather than doctors prescribing tests or treatments that work in most people but might not work for you, proponents argue, we should tailor medical interventions to unique patient characteristics, such as genomic data. (The White House's Precision Medicine initiative is an example of this kind of thinking.) Although I am skeptical that big data-driven genetic sequencing will soon trump the personalized experience of a physician sitting down and speaking with a patient, many areas of clinical medicine stand to benefit from an improved understanding of genetic and environmental causes of diseases in individuals.

On the other hand, public health problems rarely have a single cause or respond to a targeted intervention. Many policies and actions combined to lower the prevalence of smoking in U.S. adults from 45 percent in the 1960s to about 18 percent in 2013. Counseling and cessation medications played a role, but so did raising tobacco taxes; restricting advertisements; requiring warning labels; and banning smoking in airplanes, restaurants, parks, and other public places. These concurrent interventions drove a widespread culture change, making smoking "uncool" to the extent that many adults who smoke today are embarrassed by their habit.

Two stories I've read in the past month offer good examples of throwing "everything but the kitchen sink" at public health problems that defy straightforward solutions: high infant mortality and incarceration rates in African Americans. In Cincinnati, babies have been dying in the first year of life at more than twice the national average. The reasons are many: premature births, inadequate prenatal care, poor nutrition, exposure to tobacco smoke in the womb and in the cradle, to name a few. Cradle Cincinnati, the strategy that the city's medical and public health professionals created to reduce infant mortality, addresses three modifiable behavioral issues: smoking (stop), spacing (pregnancies at least 12 months apart), and sleep (baby alone, on its back, in an empty crib). Just as important was how to deliver these messages to prospective parents who were suspicious of the health system:

Using focus groups from African-American and Appalachian neighborhoods, the [nonprofit Center for Closing the] Health Gap found that many young mothers rely primarily on friends and family for maternity information: They simply don’t trust doctors and nurses. ... The distrust is often driven by not feeling valued “and not believing that the person who is giving them instruction about prenatal care even cares.” Now the Health Gap is looking for ways to train peers and neighborhood leaders to share accurate information. It’s also producing a video “letter” to community medical providers to school them in the day-to-day interactions that make a patient feel judged, devalued, and dismissed—interactions that may keep her from showing up to monitor her pregnancy or following up after her child is born.

Infant mortality in Cincinnati has fallen in each of the last few years; how much of a difference the three Ss campaign is making is hard to measure, but it does seem to be helping.

A few states northwest in Milwaukee, Wisconsin, a controversial District Attorney has been tackling a completely different but no less urgent problem: the huge racial disparity in African American men in prisons. The statistics are staggering: although they comprise only 6 percent of the state's population, African Americans represent 37 percent of the incarcerated population. A thirty-something African American man living in Milwaukee County is more likely to have served time than not. Not only are these sky-high rates devastating to relationships with partners and children, lengthy prison stays and subsequent criminal records make many former inmates unemployable.

The causes of this problem are far from obvious, certainly not as simple as the "racist police brutality" narrative that has swept the nation in recent days. Are African American men committing more crimes than others? More likely to be arrested? Being prosecuted and convicted at disproportionate rates? More likely to receive a jail term rather than parole? In Milwaukee, it turned out to be most of the above. Those who commit violent crimes should be jailed, but mandating years behind bars for shoplifting or drug possession turned teenagers and young men into hardened criminals and was ultimately counterproductive. (See my previous post for alternatives to the "war on drugs.") So D.A. John Chisholm changed the focus of his team from "winning every case" to ensuring that the punishment fit the crime, and sentencing selected nonviolent offenders to substance abuse treatment or educational programs rather than prison terms. He also charged his prosecutors with developing ways to prevent crime before it began by, for example, persuading community organizations such as Habitat to Humanity to renovate abandoned homes in low-income neighborhoods. As in Cincinnati, the jury is still out on Chisholm's methods, which have modestly shrunk the Milwaukee County prison population but doesn't seem to have affected crime rates.

Like patients with multiple complex medical conditions, public health problems require innovative solutions, but as the the executive director of Cradle Cincinnati was quoted as saying, "There's no silver bullet. It's silver buckshot, and it all needs to be fired at once." Or maybe you prefer my metaphor: everything but the kitchen sink.

Too much medical care: do we know it when we see it?

The year after I moved to Washington, DC, I visited an ophthalmologist for a routine vision examination and prescription for new glasses. Since undergoing two surgical procedures to correct a "lazy eye" as a child, I hadn't had any issues with my eyesight. Part of my examination included measurement of intraocular pressures, a test used to screen for glaucoma. Although my work for the U.S. Preventive Services Task Force was in the future, I already understood the lack of evidence to support performing this test in a young adult at low risk. Not wanting to be a difficult patient, though, I went along with it.

My intraocular pressures were completely normal. However, the ophthalmologist saw something else on her examination that she interpreted as a possible early sign of glaucoma, and recommended that I undergo more elaborate testing at a subsequent appointment, which I did a couple of weeks later. The next visit included taking many photographs of my eyes as I tracked objects across a computer screen, as well as additional measurements of my intraocular pressures. These tests weren't painful or very uncomfortable, but they made me anxious. Glaucoma can lead to blindness. Was it possible that I was affected, even though no one in my family had ever been diagnosed with this condition? Fortunately, the second ophthalmologist who reviewed my results reassured me that the tests were normal, and admitted had probably been overkill in the first place. "Dr. X [the first ophthalmologist] is a specialist in glaucoma," he said, by way of explanation. "Sometimes we tend to look a little too hard for the things we've been trained to see." (I appreciated his candor, and he has been my eye doctor ever since.)

I was reminded of this personal medical episode while reading a commentary on low-value medical care in JAMA Internal Medicine by Craig Umscheid, a physician who underwent a brain MRI after questionable findings on a routine vision examination suggested the remote possibility of multiple sclerosis, despite the absence of symptoms. Although Dr. Umscheid recognized that this expensive and anxiety-inducing test was low-value, if not worthless, he went along with it anyway. "Despite my own medical and epidemiologic training," he wrote, "it was difficult to resist his [ophthalmologist's] advice. As my physician, his decision making was important to me. I trusted his instincts and experience."

If physicians such as Dr. Umscheid and I didn't object to receiving what we recognized as too much medical care when we saw it, it should not be a surprise that, according to one study, many inappropriate tests and treatments are being provided more often, not less. 5.7% of men age 75 and older received prostate cancer screening in 2009, compared to 3.5% in 1999. 38% of adults received a complete blood count at a general medical examination in 2009, compared to 22% in 1999. 40% of adults were prescribed an antibiotic for an upper respiratory infection in 2009, compared to 38% in 1999. (If you usually have complete blood counts done at your physicals or swear by the Z-PAK to cure your common cold, we can discuss offline why both of these are bad ideas.)

One of the obstacles to reducing unnecessary medical care (also termed "overuse") is that outside of a limited set of tests and procedures, physicians and policymakers may disagree about when care is going too far. The American Board of Internal Medicine Foundation's Choosing Wisely initiative is a good start, but these lists consist of low-hanging fruit accompanied by caveats such as "low risk," "low clinical suspicion," "non-specific pain." To a clinician who feels for whatever reason that a certain non-recommended test or treatment is needed for his patient, these qualifications amount to get-out-of-jail free cards. It's easy to say that payers should just stop paying for inappropriate and potentially harmful medical care, but as an analysis from the Robert Wood Johnson Foundation explained, this is much easier said than done. If a panel of specialists convened to review the medical care that Dr. Umscheid and I received, would they unanimously deem it to have been too much? I doubt it.

Similarly, although endoscopy for uncomplicated gastroesophageal reflux disease is widely considered to be unnecessary, that didn't stop an experienced health services researcher from undergoing this low-value procedure after a few days of worsening heartburn. Comparing her personal experience to the (superior) decision-making processes that occur in veterinary medicine, Dr. Nancy Kressin wrote in JAMA:

Until patients are educated and emboldened to question the value of further testing, and until human health care clinicians include discussions of value with their diagnostic recommendations, it is hard to foresee how we can make similar progress in human medicine. Patients may be fearful that there is something seriously wrong that needs to be identified as soon as possible, they are often deferential to their clinicians' greater knowledge of the (potentially scary) possibilities, and some patients want to be sure that everything possible is done for them, without recognizing the potential harms of diagnostic tests themselves, the risks of overdiagnosis, or the sometimes limited value in knowing the cause of symptoms in determining the course of therapy.

Regardless of future insurance payment reforms, both doctors and patients will have key roles to play in recognizing when medical care is too much. More widespread uptake of shared decision-making, while hardly a panacea, would call attention to the importance of aligning care with patients' preferences and values and the need for decision aids that illustrate benefits and harms of often-overrated interventions. Changing a medical and popular culture that overvalues screening tests relative to their proven benefits may be more challenging. A survey study published in PLOS One affirmed previous findings that patients are far more enthusiastic and less skeptical about testing and screening than they are about medication, even though the harms of the former are often no less than the latter. I agree with the authors' conclusions:

Efforts to address overuse must involve professional medical associations, hospital systems, payers, and medical schools in modifying fee-for-service payment systems, enabling better coordination of care, and integrating lessons about overuse into training and continuing education. But the preferences of active patients nonetheless merit attention. Both the mistrust of pharmaceuticals and the enthusiasm for testing and screening reflect individuals’ efforts to take care of their health. The challenge is to engage patients in understanding the connection between over-testing and over-treatment, to see both as detrimental to their health, and to actively choose to do less.

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This post first appeared on Common Sense Family Doctor on January 21, 2013.

Should women start having mammograms before age 50?

The best answer to this question, I tell both my patients and loved ones, is: it depends on you.

As the U.S. Preventive Services Task Force affirmed this week in its updated draft recommendations on breast cancer screening, "The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years." The Task Force went on to suggest that women with first-degree relatives who had breast cancer might be more motivated to start screening in their 40s.

What this decision shouldn't depend on is being bullied by one's doctor into getting a mammogram "just to be safe." Screening mammography's benefits and harms are closely balanced, and as two of my mentors in preventive medicine observed, some women might reasonably decide to say no:

Over the years we have learned more about the limited benefits of screening mammography, and also more about the potential harms, including anxiety over false-positive results and overdiagnosis and overtreatment of disease that would not have caused health problems. More and more, the goal for breast cancer screening is not to maximize the number of women who have mammography, but to help women make informed decisions about screening, even if that means that some women decide not to be screened.

Two women at "average risk" for breast cancer might make different decisions after they turn 40, depending on how concerned they are about dying from cancer, being diagnosed with cancer, and their tolerance for harms of screening. One well-informed female science journalist might choose to start being screened. Another female reporter, equally well-informed, might choose to opt out. Neither of these decisions is right or wrong on an individual or population level, regardless of the apocalyptic protests of self-interested radiology groups.

What concerns me is how current quality measurement and pay-for-performance approaches could end up pressuring more doctors to behave like bullies and drive up health care costs. Fee-for-service Medicare already spends about $1 billion each year on mammography; across all payers, about 70% of U.S. women age 40 to 85 years are screened annually at a cost of just under $8 billion. Doctor A is not necessarily a better doctor who deserves higher pay than Doctor B because more of Doctor A's patients get mammograms. In fact, the opposite might easily be true.

A recent study estimated that patients and insurers in the U.S. spend an additional $4 billion annually on working up false-positive mammogram results or treating women with breast cancer overdiagnoses. That's an extraordinary amount to spend for no health benefit, and it could be substantially less if physicians had the time and resources to explain difficult concepts such as overdiagnosis. But that doesn't appear to be where we're headed.

Finally, the notion that has been written into law in nearly half of the states in the U.S. requiring that women with dense breast tissue be notified so that they can get supplemental testing for mammography-invisible cancers is particularly misguided. The USPSTF's review found no proof that breast ultrasound, MRI, or anything else improves screening outcomes in women with dense breasts, and a sizable percentage of women can transition between breast density categories over time.

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Portions of this post first appeared on the AFP Community Blog.

What can Rwanda teach the U.S. about primary care?

The relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world but rank near the back of the pack in key health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries. Although economic inequality, lack of insurance coverage, and shrinking public health budgets are also part of the problem, I'd argue that diverting dollars from redundant multi-million dollar proton beam facilities to provide a patient-centered medical home for every American would have positive effects on population health.

Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of a 2013 Atlantic headline: "Rwanda's Historic Health Recovery: What the U.S. Might Learn." Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie "Hotel Rwanda" and Immaculee Ilibagiza's memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S. But a BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to 38% of eligible U.S. girls in 2013.

Here's the thing, though: the foot soldiers in the Rwandan primary care revolution aren't doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can't afford the national health insurance premium of $2 per person? They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in a BMC Health Services Research article by the group Partners in Health:

Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.

Image courtesy of BMC Health Services Research.

The lesson to take home isn't that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this:

At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.

The problem with this upside-down pyramid is that it's inherently unstable. In Washington, DC, it's easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that don't require imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does. To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.

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This post first appeared on Common Sense Family Doctor on December 2, 2013.

Palliative care makes a difference at all ages

A troubling study published earlier this year in the Annals of Internal Medicine reported that patients and their caregivers were more likely to report pain, depression, and periodic confusion during the last year of life in 2010 than in 1998. This worsening trend occurred despite increasingly frequent calls to improve end-of-life care communication and the interim publication of practice guidelines on palliative care for adults from the National Consensus Project for Quality Palliative Care and the American College of Physicians. Although the reasons for underutilization of palliative care are not entirely clear, persistent misconceptions about these services being the equivalent of "giving up" on patients or hastening their death likely play a role.

On the other end of the age spectrum, a Close-ups in the April 1st issue of American Family Physician highlighted the benefits of providing palliative care at the beginning of life: in this case, to a baby with trisomy 13 diagnosed by prenatal genetic testing. The devastated parents testified to the importance of their family physician providing support and guidance throughout the pregnancy and after their child's birth:

She helped us understand the decisions we had to make and helped us express our goals for the care of our unborn daughter. We wanted our daughter to have a comfortable life - for however long she lived - and a natural death. At the same time, we wanted as few medical interventions as possible to avoid unnecessarily prolonging her death or suffering.

Although less well-studied than palliative care in adults, critically ill neonates and infants who received palliative care consultations spent fewer days in intensive care units, received fewer blood draws and invasive interventions, and received more referrals to chaplains and social services than comparable patients with life-limiting diagnoses. Perinatal hospice programs take perinatal palliative care one step further and provide compassionate, multidisciplinary support for parents from the time of prenatal diagnosis through the remainder of pregnancy and their child's birth and death. Clinicians who provide maternity and/or newborn care and would like to learn more about perinatal hospice can consult the website perinatalhospice.org, which lists contact information for more than 200 programs across the United States and internationally.

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This post first appeared on the AFP Community Blog.