“COLONOSCOPIES AND OTHER cancer screening tests are out — and before [age] 75…65 will be my last colonoscopy.” Those words spoken by University of Pennsylvania oncologist Ezekiel Emanuel in the October 2014 issue of Atlantic magazine, were music to my ears. Stop the hated colonoscopies, yes! Turns out it’s not so simple.
Emanuel’s article “Why I Hope to Die at 75” makes the point that a cancer diagnosis at that age usually leads to unpleasant treatment providing little gain in enjoyable or productive years. (The article elaborates on the decline in overall quality of life after that age.) His thesis was compelling for many, but at least the same number had stories about screening and/or treatment saving their life or that of someone close to them, and about the wonderful experiences they had or are having ever since.
Although many articles and books use statistics to show that screening does not save lives in the long run, these statistics need to be examined closely and personal situations seriously considered. Dartmouth Medical School professor Gilbert Welch is one spokesperson for avoiding excessive medical care, with three books on the subject, including the most recent Less Medicine, More Health.
On colon cancer, Welch cites the “Minnesota Colon Cancer Control Study — another herculean study of roughly 50,000 people followed for 15 years to conclude that “screening didn’t help people live longer. Not even a little bit.”
He acknowledges that the study didn’t focus on colonoscopies, but instead evaluated the “fecal occult blood” screening test, which detects hidden blood in the stool — but is not the most effective even among noninvasive tests.
In fact, a similarly herculean study looked at 57,600 patients in the Kaiser Permanente Northern California health care system who had colonoscopies, “unequivocally best at finding cancer and precancer,” according to an April 16 New York Times story by Jane Brody. The Kaiser study put the lifetime colon cancer risk among those not screened at more than 34 per 1,000 compared to those who had colonoscopies by the most skilled doctors at under 13 per 1,000 — which comes out to “a 50 to 60% lower risk for colon cancer and colon cancer fatalities over a patient’s lifetime,” according to a June 2015 article in HealthDay.
Welch makes many useful points about early and overdiagnosis, as well as about treatments later disproven and about how taking action may not always be the best choice. Blood pressure recommendations had remained the same for years, he notes, until in 2012 they were changed by the American Diabetes Association to raise the systolic goal from under 130 to under 140 — because prescribing medication to get pressure below a certain point had led to patient deaths.
In 1998, the respected Journal of the American Medical Association initiated the ongoing series “Less is More,” with entries that support less medical intervention. One describes a patient with Type 2 diabetes, whose doctor’s efforts to reduce his blood sugar to the prescribed level led to an episode of severe hypoglycemia, “associated with cardiovascular events, cognitive impairment, fractures and death,” after which the patient’s target level was individualized to the higher level of 7.0% (% of hemoglobin A1C, which reflects average blood sugar levels over several months).
In the ubiquitous physical exam, however, doctors generally use much the lower level of 5.7% to diagnose “pre-diabetes,” and for those with higher levels recommend dieting to decrease sugar consumption. Doctors now also commonly diagnose pre-osteoporosis, called “osteopenia,” with accompanying warnings. But “pre” anything actually means you have nothing, and while moderate changes in lifestyle might lead to better health, medical treatment for these conditions can cause more stress and worry than improved health.
For breast cancer, on the other hand, a “pre” diagnosis may be a life-saver. Ductal carcinoma in situ (DCIS), the most often-targeted in discussions about cancer overtreatment, is considered stage 0 cancer because it has not yet spread outside a breast duct. (The duct is where most breast cancer begins.) Also because DCIS was a rare diagnosis before mammography screening, health care professionals complain that regular mammographies lead to over-treatment and that DCIS should not be called cancer at all, or that it should not be treated. On the other hand, with DCIS, cancerous cells are still completely contained — in the duct — and surgery, in many cases accompanied by radiation, will completely remove the cancer as well as all future risk of cancer from that site.
Welch notes that population-wide breast cancer screening might help one in 1,000 women…”we’d all do it for the chance to be that 1, if nothing bad happened to the others…if there were no harms. But there are.” In his opinion, number one is fear — which leads to a rate of double mastectomies that Welch considers overtreatment. Of U.S. women who develop cancer in one breast — but who do not have the genetic mutation that dramatically increases breast cancer risk — about one-quarter of those now ask for both breasts to be removed, with a 30-day mortality rate after mastectomy at about a quarter of one percent.
Although DCIS is stage 0, in fact each woman receives the additional measurement of “nuclear grade,” referring to condition of the tissue. One woman whose tissue was graded 2-3 (out of 3) and “nasty,” opted for lumpectomy and radiation. Another with DCIS chose a double mastectomy and was relieved both that she had eliminated all risk, and that she would never need another mammography.
What’s difficult is how personal this process ends up being — with the burden on each individual to gather information and then weigh and sort according to their knowledge of themselves. The received wisdom is that you never know what you will decide until faced with a particular medical decision. When someone in their 70s refuses treatment for a life-threatening condition, doctors protest and tongues wag — but what should be remembered is: maybe that woman simply knows herself very well.