Coverage: MRI screening recommendations for breast cancer

The New England Journal had an editorial today by Robert Smith, Director of Screening for the American Cancer Society, in which he presented the recommendation that women deemed to be at high risk of breast cancer should be screened by magnetic resonance imaging (MRI) directed at the breast. MRI is 10 times more sensitive than mammography - in other words, it picks up a lot more small tumors - but it's also less specific - i.e., there are more false positives. Furthermore, MRI screening is expensive, on the order of 10 times the cost of mammography, so the ACS is not recommending it for all women.

What's still missing is long-term, randomized studies that show a mortality benefit from MRI screening for women at high risk - or, indeed, any risk - of breast cancer.

I chose a convenience sample of articles on this topic in the three newspaper health sections I look at regularly, the Boston Globe, Washington Post, and New York Times. Each of the articles did a good job of presenting the pros and cons. The Times focused, in particular, on the cost issue. The writers' choice of quotes from experts added interesting nuance to the arguments. To wit, from the Times:

“Just to figure out who should have it will be the hardest thing,” Dr. Morris said. “A lot of that onus is put on the referring physician. A lot of women are going to think they’re high risk, and they’re not.”

The Post article got an unfortunate headline: "Annual Breast MRIs Urged For Women at Cancer Risk." I think you can safely say that most women are at some risk of breast cancer; the high-risk part really is crucial here. But it's probably not the writer's fault. Here's my favorite quote from the Post:

"You can find a lot of cancer, but that's not the same thing as helping people live longer or better," said Russell Harris of the University of North Carolina. "It's unclear how many women really will be helped and how many will be hurt by over-diagnosis and overtreatment."

Finally, the Globe gave the last word to a breast screening advocate:

Dr. Daniel Kopans, a radiologist at Massachusetts General Hospital, said studies of MRI's usefulness in the broader population are urgently needed.

"The real question . . . is whether we should be screening all women with MRI," said Kopans, noting that nobody knows how many of the 40,910 breast cancer deaths expected this year in the United States could be prevented with MRI. "What if MR screening could knock it down by 90 percent? Is that worth $800 apiece to do MR screening for everyone? These are very important questions, and somebody is going to have to bite the bullet and do a very large, expensive study" to find out.

Is that the real question? At least he's recommending a study, rather than recommending that we just screen everyone now... And 90%? Is that an evidence-based guess? Would any of my very smart friends out there like to take on Dr. Kopans' fondest hope?

Patient safety with Paul Levy

Passing on another post at Running a Hospital, this time on forbidden abbreviations for writing prescriptions and making entries on charts.

I don't know how many of my readers are also keeping up independently with Paul's blog, so if it's unnecessary for me to keep linking to him, let me know.

But I have an ulterior motive here, which is that he'll let me interview him one of these days if I stay on his radar screen and provide him with a few extra hits. What do you say, Paul? Have I annoyed you enough yet?

Evidence against overtreatment of heart attacks

The Washington Post reports today on a new randomized trial showing that medication is as good as angioplasty with stenting in treating patients who are stable after a heart attack. Angioplasty is one of those expensive procedures that shows wide regional variation in use, begging questions about whether it's better to do a lot, or fewer. Now we have a better idea. I hope, though, that the study authors follow up and publish their findings in a peer-reviewed journal, so that everyone can have their own look at the data.

Not doing angioplasty could save a lot of money. So I wonder: is Medicare listening?

Elizabeth Edwards' breast cancer: Orac responds to the media

Orac, over at Respectful Insolence, is an oncologist and has provided extensive, helpful comments to help put the news on Elizabeth Edwards' breast cancer metastasis into context.

The Joint Commission

Over at Paul Levy's blog, Running a Hospital, an enlightening, frank discussion of the accrediting organization's role in patient safety and quality improvement. It includes an excerpt from a Boston Globe article that consists of a memo from the CEO of another hospital, Mass. General, to that hospital's staff in response to recent Joint Commission findings, and another of the commenters notes how, even though these proposed "duh" solutions seem so obvious, they're actually quite difficult to implement, and often require culture change.

I agree, and this isn't just nihilism or whining. For example, just because everyone supposedly knows that they're supposed to wash their hands between each patient encounter, it's not going to happen immediately, and the hospital has to play an active role in making it easier for staff to remember and providing more convenient, usable handwashing facilities.

It's not just me.

According to a Wall Street Journal survey, I'm not the only one who:

- has thrown prescriptions in the trash (27%)
- has thrown lab slips in the trash (13%)
- thinks doctors offer interventions (a) out of fear of litigation (52%), (b) to make more money (45%), or (c) to meet patient demands (44%)
- has switched doctors because they consider their doctor's recommendations overly aggressive (7%) (but what do I know?).

It's good to see the flip side to the conventional wisdom that patients demand x, y, and z from their docs, and will switch docs when they don't get what they ask for.

But what does all this say about communication between patients and caregivers? Maybe a Meyers-Briggs-type instrument is what we need, so that we can match patients and doctors by their aggressiveness-of-care/CYA personalities and beliefs.

Primary care news resource

Here's a website I found that covers research and other news in the primary care arena. It's in Australia. It's a little hard to read - the font is a little small and fuzzy on my screen - but it seems up-to-date and comprehensive. Anyone know of a similar resource in the U.S.? And why is it that the British Commonwealth always seems to be a few steps ahead of us on this stuff? Heck, they even cover the NIH.

Screening for lung cancer

I'll probably follow up with some of the news coverage on this story, but fellow blogger Medpundit has written a very useful summary of the new study last week showing that there is overdiagnosis in lung cancer screening.

Teamwork in health care - evidence-based?

Does teamwork in health care improve health outcomes? Nobody really knows.

Here's a 13-minute video by health journalist Ray Moynihan, who's a stickler for evidence, and filmmaker Miranda Burne. Moynihan is Australian and works a lot in the British Commonwealth, where evidence-based medicine is taken pretty seriously (see groups such as NICE and Cochrane). This film was funded by the Canadian Health Services Research Foundation, a policy group (though that's an oversimplification) that works with provider and government organizations to try and increase the uptake of research evidence into practice.

The film focuses on a program to integrate care for stroke victims. It raises some good questions: do you really need evidence when it's so obvious that an approach like team care is a good idea? My answer would be yes, if it's something that requires a lot of resources to bring about, and could have other hidden downsides. How do you get that evidence? Do you need a randomized trial? My answer: That's the best way, and you needn't rule out an RCT just because you are in a "complicated" setting with a lot of variability. Randomization takes care of a lot of that. Finally, shouldn't providers always work together as a team, just as a part of good practice, and what does "good practice" mean anyway? I'll leave that one open, but after reading some anecdotes recently about lack of coordination in hospital care, where patient charts became a sort of wastebasket for notes and lab slips that no one bothered to consult, I'd hazard that, yeah, some level of coordination probably makes sense.

What I would have liked to see more of in this film is an idea of what was meant by teamwork - is it just a series of case meetings like the one shown? How many such meetings were there? What sort of follow-up was there clinically? What does it actually mean to accumulate evidence on teamwork, and what outcomes would you look at?

Overall, though, the video is worth your 13 minutes, and provides food for thought.