Tim Trysla, Executive Director
On Behalf of the Access to Medical Imaging Coalition
The arguments put forth in this article do a disservice to patients and send detrimental mixed messages on the value of early diagnosis ??? not only for breast cancer, but for all cancers and other diseases where early detection is critical. Begley???s thesis rests on insufficient data, and quite honestly, while it tries to build upon statements from the American Cancer Society (ACS), it???s important to note that the ACS quickly distanced itself from comments proffered by its chief medical officer Dr. Brawley, saying that: "Mammography is effective -- mammograms work and women should continue get them... The American Cancer Society stands by its recommendation that women age 40 and over should receive annual mammography, and women at high risk should talk with their doctors about when screening should begin based on their family history."
Patient advocacy organizations know that cancer screenings and early disease detection save lives. Citing National Cancer Institute and American Cancer Society data, the Canary Foundation recently wrote (http://www.canaryfoundation.org/docs/PressKit/EarlyDetectionFactSheet09.pdf): ???Early detection is key in breast and prostate cancers. Five-year survival for breast- and prostate-cancer patients with early stage disease is 98% and 100%, respectively, and survival rates remain high at 10 years.???
What is the import of these statistics in the current health reform debate? When policymakers propose, as some do now, making drastic reimbursement cuts to advanced imaging, such as CT, MR, and PET, as well as imposing a severe tax on imaging equipment, it affects routine screenings such as mammography and DEXA ??? a bone-density test for osteoporosis. A study by the Moran Company shows that after the Deficit Reduction Act of 2005 cut Medicare spending for advanced imaging by 19.2 percent, growth of mammography use and spending for Medicare patients declined. The report also showed that spending for DEXA declined by 40 percent and use shrank by .2 percent.
Because proposals to cut reimbursements for advanced imaging will ultimately have negative repercussions for all screening tests, patients and patient advocates representing virtually all disease states have serious concerns. That???s why nearly thirty patient advocacy groups have written Congress and the Administration to oppose deep cuts to Medicare reimbursements for medical imaging. If you encourage your loved ones to undergo regular screenings, and believe Ms. Begley???s piece undermines well-intentioned efforts to increase disease screening rates, then you should join the growing number of patient groups calling on policymakers to preserve access to medical imaging because it saves lives and money.
Sharon Begley
It May Not Save Your Life
Why there's more reason than ever to be skeptical about cancer screening.
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Nothing about health care makes people as frantic, upset, and downright furious as being told that cancer screening is not likely to save their lives—something I learn every time I write about it. So I wouldn't want to be the poor people who handle the switchboard and e-mail at the American Cancer Society: as The New York Timesreported today, the ACS is preparing to modify its assessment of the value of some cancer screening because, as experts have known for years, it has not proved to be the lifesaver that everyone hoped and assumed. (Click here to follow Sharon Begley)
We are approaching a perfect storm on the fraught topic of screening. In this corner, more and more studies are casting doubt on the value of screening (which means running tests, often X-rays or other imaging, on people with no symptoms of disease). In the opposite corner, the debate over health-care reform has raised the dreaded specter of rationing. Any bets on whether people will believe that decreasing patients' access to screening, or decreasing insurance (especially Medicare) coverage of it, will be seen not as good medicine but as cruel and dangerous policy? Death panels indeed.
Some hint about how patients will react to any attempt to place screening on a solid scientific footing came last week. About 120 patients, doctors, and patient advocates rallied on Capitol Hill to protest provisions in the House's health-care reform bill and in the Baucus bill in the Senate that would decrease how much Medicare reimburses radiologists and others for imaging, such as MRIs and CT scans. In a letter to President Obama and Kathleen Sebelius, secretary of health and human services, 20 patient groups argued that "further deep reductions in Medicare reimbursements for diagnostic imaging would jeopardize the health of America's seniors…Limiting access to vital advanced imaging services will counteract efforts to identify and treat disease early."
If only it were that simple, or true. Unfortunately, in the case of cancer screening—again, the term refers to imaging in people with no symptoms (such as, in breast cancer, nipple discharge)—this has not been shown. As I wrote last spring, "finding a tumor when it is small should mean a better chance that surgery, radiation, and/or chemotherapy will eradicate it, allowing you to live until something else kills you. Early detection should produce clear, unquestionable benefits. Yet it doesn't. Not the PSA, not early detection of lung or testicular or pancreatic cancer, or glioblastomas, a type of brain cancer. Even mammography is iffy."
The evidence on this is abundant, but let me mention the latest. In a commentary in the current issue of The Journal of the American Medical Association, physicians urge a "rethinking" of screening for breast and prostate cancer. The basic problem, they note, is that since screening for these cancers became widespread with mammograms and the PSA test, the number of early cancers detected has gone up, but the number of advanced cancers has not. If screening worked, in the sense of catching life-threatening cancers early, then many advanced cancers would have moved into the former category—that is, been found and treated before they grew or spread. That this has not happened suggests that screening is finding many, many nonthreatening tumors that, left on their own, might never have advanced, let alone posed a threat to someone's life. In other words, the JAMA authors write, "screening may be increasing the burden of low-risk cancers without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality." Translation: screening is finding lots of tumors that doctors wind up biopsying and treating, perhaps unnecessarily. It is not saving lives.
"The benefit [of cancer screening] is not nearly as much as we hoped and comes at the cost of overdiagnosis and overtreatment," said coauthor Laura Esserman of the University of California, San Francisco, Carol Franc Buck Breast Care Center.
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