Sunday, September 18, 2016

I Really Wish You Wouldn't Do That

Digital rectal exams (DREs) typify much of what's wrong with our health care system.  Men dread going to go get them, they're unpleasant, they vividly illustrate the physician-patient hierarchy, and -- oh, by the way -- they apparently don't actually provide much value.

By the same token, routine pelvic exams for healthy women also don't have any proven value either.

The recent conclusions about DREs come from a new study.  One of the researchers, Dr. Ryan Terlecki, declared: "The evidence suggests that in most cases, it is time to abandon the digital rectal exam (DRE).  Our findings will likely be welcomed by patients and doctors alike."

No kidding.

The study actually questioned doing DREs when PSA tests were available, but it's not as if PSA tests themselves have unquestioned value.  Even the American Urological Association came out a few years ago against routine PSA tests, citing the number of false positives and resulting unnecessary treatments.

Indeed, the value of even treating the cancer that DREs and PSAs are trying to detect -- prostate cancer -- has come under new scrutiny.  A new study tracked prostate cancer patients for ten years, and found "no significant difference" in mortality between those getting surgery, radiation, or simple active monitoring.

The surgery and radiation, on the other hand, had some unwelcome side effects.  Forty-six percent of men who had their prostate removed were wearing adult diapers six months later, and impotence was reported in 88% of surgical patients and 78% of radiation patients.  The chief medical officer of the American Cancer Society admitted, "Our aggressive approach to screening and treating has resulted in more than 1 million American men getting needless treatment."

"Needless" is perhaps the most benign description of what happened to those men.

As for the pelvic exam, about three-fourths of preventive visits to OB-GYNs include them, over 60 million visits annually.  They're not very good at either identifying or ruling out ovarian cancer, and the asymptomatic conditions they can detect don't have much data to indicate that treating them early offers any advantage to simply waiting for symptoms.

Or take mammograms.  Mammograms are uncomfortable, have significant false positive/over-diagnosis rates, and costs us something like $4b annually in unnecessary costs, yet remain the "gold standard."

Not many women like them.  It has been oft-stated that if men had to get them, there would be a better method.  Yet, according to the CDC, about two-thirds of women over 40 have had a mammogram within the past two years.  Maybe they shouldn't have.

Recommendations for how often and for which ages should get mammograms vary widely, with the default often ending up being annual screenings.  However, new research has concluded that many women only need triennial screenings.  Lead author Amy Trentham-Dietz said: "Women at low risk and low breast density will experience more harms with little added benefit with annual and biennial screening compared to triennial screening."

Mammograms can find evidence of breast cancers or pre-cancers, which often leads to mastectomies.  It has been known for some time that mastectomy rates in the U.S. are much higher than other countries, but now we're seeing more mastectomies in earlier stages of breast cancer and a "perplexing" increase in bilateral mastectomies, even among women who neither have cancer in the second breast nor carry the BRCA risk mutation for it, according to a AHRQ brief earlier this year.

As AHRQ Director Rick Kronick observed: "This brief highlights changing patterns of care for breast cancer and the need for further evidence about the effects of choices women are making on their health, well-being and safety."

In less diplomatic terms: what the hell?

Then there is everyone's favorite test -- colonoscopies.  Only about two-thirds of us are getting them as often as recommended, and over a quarter of us have never had one.  There are other alternatives, including a "virtual" colonoscopy and now even a pill version of it, but neither has done much to displace the traditional colonoscopy.  And all of those options still require what many regard as the worst part of the procedure, the prep cleansing.

An option that avoids not only the procedure but also the prep hasn't taken root either.  It involves collecting a sample of one's stool to test the blood.  This option, such as fecal immunochemical test (FIT) or fecal occult blood test (FOBT), has strong research support, to the point that the Canadian Task Force on Preventive Care says it, not colonoscopies, should be the first line of screening.  It is also much cheaper than a colonoscopy.  In the U.S., though, colonoscopies remain the preferred option for physicians.  

The final example is what researchers recently called an "epidemic" of thyroid cancer, which they attributed to overdiagnosis.  In the U.S., for example, annual incidence tripled from 1975 to 2009.  They found that the rates of the cancer were tied to the increased availability of diagnostic tests like ultrasound and CT scans, which led to the discovery of more cancers.  The researchers believe that as many as 80% of the tumors discovered were small benign ones, which did not mean they weren't surgically treated.

In fact, according to the researchers: "The majority of the overdiagnosed thyroid cancer cases undergo total thyroidectomy and frequently other harmful treatments, like neck lymph node dissection and radiotherapy, without proven benefits in terms of improved survival."  Not only that, once they've had the surgery, most patients will have to take thyroid hormones the rest of their lives.  

All of these examples happen to relate to cancer, although there certainly are similar examples with other diseases/conditions (e.g., appendectomy versus antibiotics for uncomplicated appendicitis).

Two conclusions:

1.  If we're going to have unpleasant things done to us, they better be based on facts: As the above examples illustrate, some of our common treatments and tests are based on tradition and/or outdated science.  We deserve better than that.  We should demand the options and the evidence.

2.  We should do everything we can to make unpleasant things, well, less unpleasant:  Physicians can't just focus on reducing patients' medical complaints but also should seek to reduce other complaints about their care.  When patients dread having something done, and often use that as an excuse not to get services, that should be a tip-off that something needs to change.

Let's get right on those.


  1. None of us like to have our bodies probed, but in my opinion as a critical are nurse, the human touch is important. A doctor can 'feel things' that machines cannot. I put off having a colonoscopy for years. Once I had it done, I realized it was my fears and they were unfounded. Here is the blog post I wrote from that experience.

  2. There's a substantial patient demand for overtreatment. Look at the discussion about thyroid ca in the LinkedIn 'society for particapatory medicine' group, where the poster objected angrily to the idea of 'restricting' treatment based on 'statistics.'
    The tendency to reason from personal experience rather than data is all too human, and all too common.

    1. No doubt. Much patient demand in those mastectomy and prostate surgery numbers, for example...probably less for DREs. Need to help patients act less out of fear.

  3. If you hanker after getting tarred and feathered, voice scientific doubt about mammography-the net effect for 10,000 women 50-70 over 20 years is 2-3 women die of treatment rather than breast ca.: