CT gone wild

Last week Dr. Jerome Kassirer, professor at Tufts University School of Medicine wrote an insightful op-ed piece in the Boston Globe. Stemming the craze on CT scans highlights a rush by some elements of the medical profession for the widespread use of CT scans for early screening –like screening all smokers. According to one group of cardiologists, 90,000 deaths could be prevented and billions of dollars saved. (Happy Valentine’s Day I guess.) According to a group of radiologists, 90 percent of lung cancers could be caught early and cured. The broader medical societies, to their credit, have not gone along with these uncontrolled studies. As a result, some of the proponents have taken their case to state legislatures to mandate reimbursement for such procedures.

Kassirer points out that these recommendations may be financially motivated and then he describes some of the financial and clinical problems associated with widespread screening:

How do we know whether these screening recommendations are motivated by concern for patients’ welfare or money, or perhaps both? We don’t. But widespread screening for lung cancer and heart disease can be risky and will be expensive. Experience shows that every time we approve a screening procedure, it is used more widely than the indications for which it was originally approved. More screening machines invariably lead to more tests; more tests yield more false positive results, more risk to screened patients, and more expense.

Testing decisions must be made by organizations that sort through all the evidence. They must appoint guideline committees that are not influenced by how much their colleagues make or how many pills the companies sell that pay them to speak or consult. We are nearly at the limit of our expenditures on medical care; we don’t need more expenses for tests that have been tainted by possible financial bias. We must remember who will pay for all these additional tests: you and me.

Kassirer doesn’t have space in his article to be more specific about the risks. Radiation from unneeded CTs is one problem (see Image gently, or when the diagnostic is worse than the disease), another is the dangers from invasive follow-up procedures. Collapsed lung from an unnecessary biopsy, anyone?

A follow-up letter to the editor (Talk is cheap if CT scan is invaluable) from someone who feels his wife was saved by early CT screening shows how difficult a sober argument like Kassirer’s is to convey.

I am not a doctor, but I am a husband – a husband of a nonsmoking wife whose life has been dramatically extended by the use of CT scans in detecting her lung cancer. This is only one case, but it is my case, and for me it’s convincing. So I say to the naysayers, the technical or ethical nitpickers, you can question CT scans’ viability till the cows come home. But when someone close to you is dying, and you think that if you had used CT scans you might have saved that life, all the pro-and-con arguments will have been worthless. You will have rejected the one tool that could have helped. That is something I will not do with my family.

The letter’s author may or may not have a valid point about his wife’s specific case. There’s not enough information in the letter to know what really happened. Still, there’s no reason to make policy based on anecdotes. The Globe could publish letters about people who died of an infection after a follow-up procedure or were traumatized by wrongly thinking they had cancer.
It is reasonable for patients to be skeptical about whether a test or treatment is being withheld for cost control reasons rather than clinical reasons. In the case of CT in the US, the bias is usually toward too much testing rather than too little.

February 14, 2008

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