Sunday, March 13, 2011

Breast Cancer Breakthrough: Can It Break Through?

Recently, every newspaper in the country reported on a landmark development in breast cancer treatment. It is now clear that certain breast cancer women do not need to undergo removal of lymph nodes from the armpit as part of their treatment. This would spare them from the risk and discomfort of an unnecessary procedure. It is welcome news, particularly for those of us who argue that in medicine, less is more. This is an example of the benefit of comparative effectiveness research, a tool that can separate what patients truly need from what the medical profession believes they must have.

Let’s hope that breast cancer breakthrough metastasizes across the medical profession. Here’s what it accomplished.

  • It spares women from unnecessary surgery.
  • It saves money.
  • It demonstrates that physicians and medical professionals can serve the public interest.
  • It gives hope that all medical specialties will critically evaluate and justify the tests and treatments that we recommend to our patients.
Ironically, when the U.S Preventive Services Task Force (USPSTF) published their mammography guidelines last year, also arguing that less is more, they were assailed as medical traitors against women.

When it comes to breasts

There’s a tug of war

Some want less

And some want more.

Every practicing physician, medical educator and researcher should examine their own practices and medical advice. On what basis do we recommend our treatments? Do we do so because we were taught these practices in our training years ago? Is it from habit or adhering to the community standard? Is it because patients have such a high expectation of a medical intervention that we feel obligated to act?

Can anyone argue that patients are subjected to too much/many

  • Chemotherapy
  • Antibiotics
  • Colonoscopies
  • Cardiac stents
  • CAT scans and their imaging cousins
We are overtesting, overtreating and overwhelming a system that is sagging under the tonnage of well-meaning and ineffective medical care. I am not referring here to the universe of medical care that serves various constituencies’ economic interests. I speak here about physicians who are trying to do right, but are not accomplishing their objectives. Our aim is true, but we are misfiring.

Weeks ago, I reviewed an outstanding book called Overtreated, which I would mandate every medical student and physician to read as a requirement for maintaining their licensure. This theme is the thread that winds itself through the Whistleblower blog, to the delight of some, and the consternation of others.

If this recent breast cancer message caught fire, medical quality would be launched into the stratosphere. Then, true medical quality would be out of reach of the bureaucratic bean counters and pay-for-performance charlatans who champion medical quality as they proceed to dismantle it.

Let’s hope that this breast cancer study will become the mother’s milk of medicine.

3 comments:

A. Bailey said...

Hmm. What percent of the colonoscopies that you perform are unnecessary? And why do you go ahead and perform them anyway? And how many people are out there that you should have performed colonoscopies on that did not receive them?

Michael Kirsch, M.D. said...

@ A. Bailey, my fellow GI. I have already admitted in the blog that at times my criteria for performing procedures is elastic. (See http://bit.ly/cRJYQh).

How many of my (our) procedures are unnecessary? How many decades might it take to define 'unnecessary'? Thanks for your comment.

A. Bailey said...

I went back to read your referenced post. It was very good.

One interesting category of procedures is "done because my family doctor/my next door neighbor/the ad campaign on TV convinced me I have cancer". I had one such procedure kicked back to me recently (it doesn't happen very often) and I'm actually looking for the V code that includes "test done for reassurance because someone scared the crap out of the patient". I know there is such a code.

Sorry for the aside. We work in a weird system.

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