"Caring For Yourself" By Allen Weiss, MD, MBA, President and CEO

Caring For Yourself

January 15, 2010 - New guidelines for breast cancer screening and Pap smear screening have been all over the news in recent months.

These are just two examples of recent healthcare recommendations, based on age and gender screening, which seem to fly directly in the face of long-held beliefs. Both the new recommendations and the old standards come from legitimate and credible medical resources. What should a conscientious person do? Who is correct? Is there a difference about what is appropriate for a community as opposed to an individual?

Senator Daniel Patrick Moynihan once famously stated, “Everyone is entitled to their own opinion, but not their own facts.” The facts in these situations are evolving toward more evidence-based guidelines (also known as “comparative effectiveness” when applied by the government to assess the efficacy of various diagnostic tests and therapeutic procedures). And that means we will have more dilemmas to face.

Many experts suggest mandating evidence-based medicine, which comprises guidelines for best practices, as established by practitioners from medical outcomes research studies. This would allow more predictable results for patients, because the current 40% variation in treatment for the same diagnosis would be reduced to near zero. For example, only 59% of Medicare patients with cancer receive “best practices,” according to the National Quality Forum (www.qualityforum.org/ ), while only 55% of all U. S. patients receive recommended care, according to RAND Corp (https://email.nchmd.org/exchweb/bin/redir.asp?URL=http://www.rand.org/research_areas/health/).

Quality of care varies considerably by medical condition. People with cataracts receive about 79% of recommended care. Patients with alcohol dependence receive only about 11% of recommended care. People with diabetes receive only 45% of the care they need. Fewer than half of patients with diabetes have their blood sugar levels measured on a regular basis. 32% of patients with coronary heart disease obtain recommended care, and only 45% of patients who suffer a heart attack receive medications that could reduce their risk of death by more than 20%. All of this data comes from the Health Leaders October 2009 issue.

Let's consider the recent controversy about breast cancer screening, and start with some facts as shared in the United States Preventive Services Task Force paper. The original 21-page paper was published in the Annals of Internal Medicine in November, 2009. It is entitled, “Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms.” (www.annals.org/content/151/10/738.full)

The facts in the paper are based on 20 different screening strategies involving women born in 1960 and followed from age 25. The chance of a women having breast cancer ranges from 12% to 15% with about 3% of women dying of this disease. Various screening schedules were reviewed for their value, which in this study was defined as mortality divided by cost.

In the conclusion discussion from this Task Force paper, there are two goals mentioned which are notably different and point out that the goal for an individual is different than the results for a community. Here is the exact quote:

· “If the goal of a national screening program is to reduce mortality in the most efficient manner, then programs that screen biennially from age 50 years to age 69, 74, or 79 years are among the most efficient on the basis of the ratio of benefits to the number of screening examinations. If the goal of a screening program is to efficiently maximize the number of life-years gained, then the preferred strategy would be to screen biennially starting at age 40 years. Decisions about the best starting and stopping ages depend on tolerance for false-positives results and rates of over-diagnosis.”

False positive and false negative results are more common in the under-50 age group, which causes the authors to argue against starting the screening too early.

The bottom line for mammogram screening is that the goals are different for an individual versus the community. Most individuals want everything to be done and are willing to deal with the risks of false positives. Most individuals are unconcerned about the overall cost. But a community or healthcare system is concerned about total value, which takes into account cost and results.

Another controversial area which has been recently reviewed with an eye to change is the Pap smear (which was named for Dr. George Papanicolaou, who invented the test). The current recommendation from the American College of Obstetrics and Gynecology has changed to an initial cervical cancer screening at age 21, and rescreening less frequently than previously recommended—from annually to once every two years. And thereafter, every three years starting at age 30 if the woman has had three negative tests. These recommendations will result in a significant decrease in the number of women who have Pap smears each year—which, in turn, will save on health care costs without affecting outcomes.

An important exception for both mammography screening and Pap smears relates to women at risk either through family history or exposure to known carcinogenic (cancer-causing) agents such as human papillomavirus.

So to update Sen. Moynihan's comment, we now have new facts to sort out, and new opinions to be formed.

While that's taking place, the bottom line for an individual is to stay informed, be diligent and be attentive to recommended screenings. (The percentage of Americans who are participating with recommended screenings is surprisingly low. It's only about one-quarter of the 50-64 age group, according to the U. S. Centers for Disease Control and Prevention, AARP, and the American Medical Association.)

That's good advice to make you feel better—and improve your quality of life.


Dr. Allen Weiss is CEO & President of the NCH Healthcare System. He is board certified in Internal Medicine, Rheumatology and Geriatrics, and was in private practice in Naples, Florida from 1977 - 2000. Dr. Weiss is active in a variety of professional organizations and boards, and has been published in numerous medical journals, including the American Journal of Medicine and the Journal of Clinical Investigation.