Cancer screening: how conventional wisdom, quality indicators, and payment incentive equals poor outcome
August 11, 2015
Cancer screening is perceived to be a very effective way to prevent serious illness. Pap smears, mammograms, colonoscopies, and even PSA blood tests can detect cancer early and lead to improved outcome. But just how effective are these tests at detecting early cancers and helping patients to live longer and better? Are there any dangers of getting these tests, which on the surface seem harmless? I talk a great deal about this topic in my book, and in many cases, especially in the elderly, screening tests are more harmful than helpful. While this seems counter-intuitive, it is based on ample research. Many such tests are endorsed by Medicare’s quality indicators, and the failure of our patients to have these tests is viewed by Medicare as being indicative of us providing low quality medical care, something that will soon lead to cuts in our pay.
A recent Baltimore Sun article from July 9th showed the disparity between what we know about screening and what patients actually get done. “Getting tested too often can do more harm than good,” the article states, relying on data that has been apparent to us for some time. And yet, many patients pursue such testing despite the lack of benefit and the risk of harm. 50% of woman over 80 get mammograms despite the fact that there is no demonstrable benefit and there is potential harm; in fact, the vast majority of women even in appropriate age groups get mammograms annually even though it is recommended only every other year. 70% of women without a cervix get a pap smear, even though such tests only detect cancer in the cervix; many women with cervixes get pap smears very year, even though it is recommended they get such tests every 3-5 years up to age 65, and then none after that. 60% of people have colonoscopies more frequently than guidelines suggest, and half of men over 75 have PSA blood tests even though they may cause more harm than good.
All of these seemingly innocuous cancer screens can lead to over-testing, over-treatment, serious harm, and even death. None of them, when done inappropriately, have been shown to save lives or to reduce cancer death. Somehow much of the population has been sold on the illusion that with enough testing we can find and eliminate cancers, something that is absolutely false. Most concerning, Medicare continues to pay for these tests. The radiology group that sends my elderly patients a letter that it is time for the annual mammogram, the gynecologist that performs a pap smear on a woman without a cervix, the gastroenterologist who suggests more frequent follow-up colonoscopies just to be thorough, the doctor who continues to order PSA tests on elderly men and to perform biopsies if the PSA is positive all get paid well by Medicare for encouraging testing that is harmful. In fact, all of these doctors are practicing quality medical care by Medicare’s clinical guidelines.
Whether with cancer screening or cardiac stress tests or CT scans for back pain, inappropriate and excessive use of procedures that are sold to patients as being life saving, despite being just the opposite, should not continued to be endorsed by Medicare. By paying doctors very well to over-test people, by having no quality indicators that dissuade doctors from performing inappropriate tests, and by giving patients unfettered access to such tests, Medicare is actually facilitating harmful medical practices that cost society hundreds of millions of dollars of squandered money and cost many patients their lives. We know which tests actually are helpful and which are not much of the time, and that knowledge has yet to be inscribed in Medicare’s rules and payment formula. As such, far too many patients are receiving dangerous care that is enriching many doctors. It is time that Medicare use medical science to determine what it will finance, rather than basing its decisions on illusory whim.