The rest of the medical adventures to skip - Part 2

More from choosingwisely.org on medical adventures to skip:

American College of Radiology:
- No imaging for uncomplicated headaches - just take a damn aspirin will you.
- No imaging for suspected pulmonary embolism without moderate or pre-test probability
- No preop or preadmission chest x-rays for ambulatory patients without history
- No CTs for evaluation in appendicitis until an ultrasound has been considered.
- No follow up imaging for inconsequential cysts unless over 1 cm

American Gastroenterological Association
- Translator needed for this one but I believe it means don't over medicate for GERD: For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
- Colonoscopies only once every ten years if clean
- Colonoscopies not repeated for at least five years who have small polyps that were removed during a colonoscopy.
- Do not repeat endocscopy for at least 3 years with Barretts esophagus patients without cellular changes.
- CT scans do not need to be repeated for abdominal pain unless clinical findings or symptoms

American Association of Nephrology
- Skip routine cancer screenings for dialysis patients with limited life expectancies who are asymptomatic
- No ESAs to reach normal hemoglobin levels in chronic kidney disease patients
- No NSAIDs to patients with hypertension, heart failure or CKD.
- No PICC lines in Stage III-V CKD patients without consulting a nephrologist.
- Consult patients, families and physicians before starting chronic dialysis - a group decision

American Society of Nuclear Cardiology
- No stress tests or coronary angiography on patients without cardiac symptoms unless high risk markers are present
- no cardiac imaging for patients who are at low risk
- No radionuclide imaging as part of routine follow up in asymptomatic patients.
- No preoperative cardiac imaging as preoperative assessment in patients before  low or medium risk non cardiac surgery
- Reduce radiation exposure in cardiac imaging tests including not performing tests when limited benefits are  likely

After having read all these (and written them down) my thoughts are I am happy to see these recommendations. If there is no need, why are they running the tests? Just because a new test comes along and it shows some benefit, if over time, the becomes proven that there is no real benefit, why do we keep running it? If a patient has no symptoms why do they need a test?  We have all been trained by our doctors to expect test after test or magic pill after magic pill. But maybe just go take an aspirin and wait a few days. And a headache doesn't mean its a brain tumor.

Juggling the patient's peace of mind vs. costs vs. over diagnosis can be difficult but if in the long run there is no real benefit, feel free to skip my tests, thank you.

More medical adventures to skip - Part 1

More medical specialty societies have created lists of "Five things Physicians and Patients Should Question" - Thank God I found a copy of this list that was NOT in the format of a list of pictures and graphics so we don't have to read. The media believes that the average American can't read and needs lists of things and images to flip through so we can understand what they are saying (One of my new pet peeves - write down letters and words instead of pictures - I don't even need to run my finger under each line to follow along, nor do I sound the words out as I read. We are also so stupid we need to have the same stories over and over again reported down to a microscope level long after we couldn't care less any more.)

To see the  lists yourself, go to choosingwisely.org and click on the lists link on the top which provides more details than I can decipher. But here is a summary:

From the American Academy of Allergy, Asthma & Immunology: \
- Don't perform unproven diagnostic tests.
- Don't order sinus CT or indiscriminately prescribe antibiotics for sniffles
- Don't do routine diagnostic testing in patients with hives
- Don't recommend replacement immunoglobulin therapy for recurrent infections unless there are poor responses to vaccines.
- Don't diagnose or manage asthma without spirometry - in other words do not assume

American Academy of Family Physicians
- No imaging for low back pain in the first six weeks unless there are red flags
- Don't routinely prescribe antibiotics for a cold unless the symptoms last longer than 7 days or worsen
- Don't use DEXA screening for bone density in women under 65 or men under 70 with no risk factors
- Don't order EKG's for patients without symptoms
- No pap smears on women under 25 or who have had a hysterectomy for non-cancerous reasons.

American College of Cardiology
- No stress tests or advanced non invasive imaging in the intial evaluation of patients without cardiac symptoms unless high-risk markers are present
- No annual stress tests of advanced non-invasive imaging in routine follow up on patients with no symptoms
- Do cardia imaging or stress tests as a pre-operative assessment on patients as part of low-risk, non cardiac surgery
- No ECG as routine follow up for adult patients with no symptoms
- No stents unless specific criteria met - must meet the big word description that I don't understand.

American College of Physicians
- No stress tests on patients with no symptoms and who are not at risk for coronary heart disease.
- No imaging studies on patients with non-specific low back pain.
- No CT or MRI of brains unless symptoms are present.
- Use D-dimer measurement as initial diagnostic step for VTE and if negative, no more tests are needed.
- Skip the preoperative chest x-ray unless symptoms are present.

I see some repetition here. I bet many of these were ordered as a CYA move to prevent malpractice law suits based on recommendations from the doctor's insurers.

More tomorrow

Hold that test!

Yes, skip some of those lovely little medical adventures, please. I have heard in the news that 9 medical boards have recommended 40 something tests/procedures (a/k/a medical adventures)  to help reduce medical costs. I have heard a few of them - skip antibiotics for the common cold for example - but wasn't sure of the rest. In the days of high medical costs, over diagnosis, and over treatment, any little adventure we can skip, save me a seat! I heard some appalling number the other day of something like $3 trillion is the amount Americans spend on medical care each year - and I might be missing a digit  maybe $35 trillion?

ASCO, or the American Society of Clinical Oncology, has made five recommendations of tests or treatments for cancer patients.

"The list emerged from a two-year effort by an American Society of Clinical Oncology (ASCO) task force, similar to a project other medical specialties are undertaking, to identify procedures that do not help patients live longer or better or that may even be harmful, yet are routinely performed.

As much as 30% of health-care spending goes to procedures, tests, and hospital stays that do not improve a patient's health, according to a 2008 analysis by the nonpartisan Congressional Budget office."

The first recommendation is: "...that patients who have been successfully treated for breast cancer and have no symptoms of cancer not undergo CT, PET, other imaging, or bone scans to check for recurrence."

ASCO recommends against routine use of four other procedures: chemotherapy for patients with advanced cancers who are unlikely to benefit; advanced imaging technologies such as CT and PET or bone scans to stage early breast and prostate cancers at low risk for metastasis; and drugs to stimulate white blood cell production in patients receiving chemotherapy if they have a risk of febrile neutropenia."

Hmmm... I had a bone scan at my breast cancer diagnosis because I was also experiencing some weird leg pain issues. I did have a PET scan after treatment at one point because there was a 'suspicion' and with my history they need to be sure (blah, blah, blah). I was also hospitalized for febrile neutropenia in the middle of chemo and then had some drugs to take (which I cant remember their name or exactly when) after each session of that chemo.


So what do I think of these changes? I know they are being done with an eye on controlling costs. However some of these greatly ease the patient's mind. If all my friends are getting PET scans why aren't I getting them too - the lemming mentality? I see it all the time on cancer boards. 'I get that test twice a year, you demand your doctor get you that test as well.'  People often don't think about costs when their insurance pays for them.  And peace of mind is invaluable to patients during and after treatment - they just want to make sure its not there.

While I see benefit in annual mammograms for women with or without a breast cancer diagnosis, I do not really see the benefit of regular CT, PET or bone scans for asymptomatic cancer patients. Fewer trips to the hospital make me a happy girl.

Finally while these are guidelines meaning they are general rules, each cancer patient needs to talk to their doctor about what is appropriate for their needs. A good doctor will be able to give solid reasons why or why not a medical adventure is needed. So once again, go talk to your doctor and see what is right for you.

Another treatment 'advancement'

The latest suggestion for breast surgery is to use ultrasound guidance during surgery to improve odds for clean margins and therefore local or regional recurrences and the requirement for a second surgery. This sounds good. It is based on a small European study but is now suggested as being the newest standard of treatment.

Well that is just ducky. I mean who wouldn't want an advancement in treatment. But (and of course there is a big but here), I have a few questions on this:

1. When would this become the standard of treatment? Does the FDA have to approve it? Probably not, but probably the Surgeon's Standard Board Association or whatever they are called - the people who set the surgical standards. So this will probably take a while. Hospitals would need to adopt the standard and then individual surgeons would need to be trained -  how do you hold the ultrasound thingy and cut into someone? Even if its held by someone else, isn't it be held on top of the thing the doctor is trying to remove? Maybe its a good idea I'm not a surgeon. (Not that I am any better off as being the patient.)
2. While this has the potential for saving some lives,  is there an increased cost involved? Do all hospital surgery rooms have the right kind of ultrasound machines for this or do new machines need to be purchased? In the age of eyes on increasing medical costs, increased expenses go under the microscope. While I am not trying to put a value on an individual's life but we have to consider this. If hospitals need to purchase more ultrasound machines for this surgery, could that money be better used by them for hiring more nurses to provide better care or a different machine for another use? Yes in an ideal world, hospitals would all have all the money, personnel, and machines they need - but we live in reality, not an ideal place.
3. This was based on a TINY study of 124 patients and one group of surgeons? Is this representative of all patients and all surgeons? Maybe more studies are needed - or at least at more than one hospital.

I am a tad skeptical but would welcome the progress - and just hope I would never need it.

I am confused

I know it is a leap but this confusing information has overwhelmed my tiny chemo brain. One article says yes and one article says no. This article about a Dutch study says that breast cancer screenings save lives. This article about a Norwegian study talks about how screenings in your 40s can lead to over diagnosis and over treatment of breast cancer.

So what to do? This really becomes a matter of personal choice (unless the evil health insurance companies make the decision for you) of when to start screenings of any kind. But once you start you need to realize that you do run the risk of being over diagnosed and over treated. Some cancers will never cause a problem for the patient later in life. But do they really know how to tell which one is not going to be a problem? I'm not sure.

This is a problem we have with medical studies in general. There will be one which says one thing and another that says the exact opposite. And both require more studies to prove right or wrong. How helpful. How confusing. 

Ambulance chasing law suits

There are more lawyer jokes I think that any other profession, maybe except golf jokes. 'What do you call 1000 lawyers at the bottom of the sea? A good start.' Ha, ha.

I am not a lawyer, I am a marketing person who also works in the non profit world. There is an overlap there. For a few years I worked for a legal non profit promoting continuing education for attorneys. Through that job, I met MANY lawyers. Most of them were nice normal people practicing law (why do lawyers and doctors practice when the rest of us work?) but some of them were not in it for altruistic reasons, they were in it for the money. You could tell. But I digress.

The one thing that I really detest about the practice of law is the ambulance chasing syndrome. I read a book recently by a former attorney, now author (who's name escapes my chemo brain) about a law office near a bad intersection. At every accident at the intersection, they would run out and assess the litigation potential. It is not unknown. We also see the billboards near many cities - "Have you been subject to medical neglect? Did your doctors do you harm? Call us toll free and we can sue!' Lovely people, lovely premise.

But what really burns me up are the ones who focus on a cancer diagnosis. Did your doctor miss your tumor? We can sue! Did you know the odds of survival are lower for breast cancer detected at later stages? They promise to address 'delayed diagnosis due to doctor oversight'.  These people are the cause of rising malpractice premiums forcing doctors out of medicine. Thank you (not).

With someone with a couple of cancer diagnoses under my belt, I can tell you one of the biggest issues we have when facing a diagnosis is why didn't we get it ahead of time? Why, why, why? We spend many hours wondering why we were the ones with cancer, why they didn't find it sooner, and the big one - am I going to live? And the ambulance chasers prey on these fears and making it even more difficult to cope with the cancer roller coaster.

I am not saying that doctors never make mistakes - they are human after all. But a tumor has to reach a certain size before it is detectable by current technology. There are also many more benign tumors than malignant tumors. Sometimes mediation is needed and possibly litigation but that is not the correct way to address a medical error. Start with a conversation and not a lawsuit.

XRCC2

Do you know the secret handshake that tells you what this is? Hmmm.... I'm not sure if I can tell you. Do you have the clearance? Pinky swear you are okay to know?

Its another breast cancer gene that was recently discovered by Australian researchers. This is very important. The BRCA genes only account for 10-20% of all breast cancer diagnoses. Another gene may not account for as many but it is the next step in discovering more genetic mutations which lead to breast cancer and other cancers.

The significance of this breakthrough is due to the latest type of gene sequencing - called 'massively parallel technology'. Now that's a mouthful. But if it works and creates progress, I don't care how many big words they use.

I also hope that with the discovery of another gene, Myriad Genetics, which thinks they 'own' the BRCA genes, will
lose their ability to 'keep' their gene.