CT scans don't cause cancer, Radiologists who overuse CT's increase risk

Two studies were published in the Archives of Internal Medicine this past Monday showing "The risk of cancer associated with popular CT scans appears to be greater than previously believed".

I originally read this article in the WSJ and they included a nifty graph showing the increase in CT scans over the years (1993-2006, and included projected 2007 numbers). I can't say I was shocked. Obviously there will be an increase, population increases year over year.

As expected, the American College of Radiology (ACR), released their own statement in response to the recent studies. The ACR statement was wonderfully put together and basically stated that if an imaging center abides by the standards put forth, then there should be no increased risk as the benefit of the scan outweighs the risk. Seems like common sense to me.

This is where I believe that patients need to take more responsibility for their own health by asking questions instead of just going along with whatever their physician says. After all, when you break it down, its a business that strives to make a profit. I am not putting down all clinicians who perform CTs, I am putting down the clinicians who abuse the system to make the money to pay for their fancy state-of-the-art equipment. Those machines come with a hefty price tag and the ROI must be met somehow. Some clinicians go about it the right way, others don't unfortunately. They are human after all.

Now for the other issue with this...clinicians have to protect themselves. If a patient comes in complaining of a mild condition that a CT may show, its up to the doc to determine the severity of the situation. This is a very fine line due to the liability involved. Unfortunately we live in a world of money hungry individuals who are willing to sue if their coffee if too hot. This is where the relationship of the physician and patient comes into play. There has to be a level of understanding and trust for the situation at hand.

Personally, I have a wonderful relationship with my GP and others specialists that I see because I feel comfortable with them. If you don't feel comfortable asking the hard questions with your provider, maybe its time to look into a different one. Good ones are out there, more good than bad fortunately for us. But it is up to us to sift through the population to find one that fits best. Unfortunately for doctors now a days, it is getting harder and harder to make money and that is unfortunate because I believe that some of the "good" docs may be susceptible to becoming more focused on business side rather than patient care, which I can't say I don't necessarily blame them, they have bills to pay too, big ones like student loans, salaries, mandatory EMR adoption etc.

Now for my cynical comment....I wonder which diagnostic test or treatment or whatever will be next to take some heat in order to cut healthcare costs? Keep in mind this is at the expense of the public who desperately wants change, but I have to ask, at what price? So far it has been more about money than human lives.

National Consortium of Breast Centers just announced stance on new Mammography guideline changes

The National Consortium of Breast Centers (NCBC) has just released their position statement regarding the recent mammography guideline changes:

“The National Consortium of Breast Center's Board of Trustees has given their consent to the following position statement reflecting their stand on the issue of mammographic screening, in response to the recommendations made by the US Preventive Services Task Force.

National Consortium of Breast Centers, Inc.

Position Statement regarding the Mammography Screening Recommendations of the United States Preventive Services Task Force (USPSTF)

The National Consortium of Breast Centers (NCBC), the largest national organization devoted to the inter-disciplinary care of breast disease, requests the USPSTF rescind their new position on mammography screening.

The U.S. Preventive Services Task Force (USPSTF) published a paper detailing model estimates of potential benefits and harms to women screened for breast cancer with mammography.1 They provided an updated USPSTF recommendation statement on screening for breast cancer for the general population that alters currently accepted guidelines for women over 40 years old.2

The NCBC opposes the new guidelines as written. We cite specific evidence that screening mammography leads to early detection which leads to improved survival.3 In every country starting population screening, mortality declines coincide with onset of screening, not systemic therapy. These USPSTF models are not based on sound data, namely different denominators in the “harms” vs. “benefits” groups leading to invalid comparisons. Recent data from randomized controlled trials reveal significant mortality reductions evident approximately five years after screening programs were initiated. The reductions in age-adjusted, disease specific mortality (30-40%) since 1990 define screening program benefits not seen in the prior six decades. In the United States, these mortality declines continue at a rate of approximately 2% per year. 4 This mortality improvement counts as a remarkable public health achievement.

In addition, the USPSTF panel (comprised almost exclusively of primary care physicians) did not include breast imaging specialists nor was it represented by any of the multiple other specialists who collaborate to optimize patient outcomes. These specialists include pathologists, surgeons, medical oncologists, radiation oncologists, reconstructive surgeons, technologists, geneticists, nurse navigators, educators and others.

The NCBC does not understand the assumptions used by the USPSTF to value human life. We note the cited literature was selective and failed to acknowledge equally powerful and credible peer-reviewed literature, which supports currently accepted breast cancer screening guidelines.

We would also like to note that quality of life has a significant value, not just survival. It is well established that if we discontinue mammography for women in their 40’s, the cancers eventually detected will be larger, more likely need more aggressive surgery, more likely need chemotherapy and more likely lead to other significant socio-economic concerns.

The NCBC requests input into future guideline development and vows to work with government, scientists and industry to keep the process transparent and keep the focus on the patient. We recommend further efforts target screening, risk assessment, education and awareness regarding the implications of positive and negative screening findings. Funding for further research is imperative and supported by the controversy these articles have generated.

Finally, we note the USPSTF article states, “whether it will be practical or acceptable to change the existing U.S. practice of annual screening cannot be addressed by our models.”1 The NCBC agrees with this comment and finds their screening guideline suggestions unacceptable. The NCBC believes many women’s lives will be placed at risk if current screening guidelines are altered. We respectfully request the Task Force rescind their position on this specific women’s healthcare screening policy.

# # # #

About NCBC: The National Consortium of Breast Centers (NCBC) is the largest national organization devoted to the inter-disciplinary care of breast disease. In keeping with our mission, to promote excellence in breast care through a network of diverse professionals dedicated to the active exchange of ideas and resources including: 1) To serve as an informational resource and to provide support services to those rendering care to people with breast disease through educational programs, newsletters, a national directory, and patient forums; 2) To encourage professionals to concentrate and specialize in activities related to breast disease; 3) To encourage the development of programs and centers that address breast disease and promote breast health; 4) To facilitate collaborative research opportunities on issues of breast health; and 5) To develop a set of core measures to define, improve and sustain quality standards in comprehensive breast programs and centers.

References:

1. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 738-747.

2. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 716-726.

3. Tabar L, Vitak B, Chen HT et al. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast cancer mortality. Cancer 2001; 91: 1724-1731.

4. American Cancer Society, Breast Cancer Facts and Figures, 2009-2010.

All content and design © 2009 by the National Consortium of Breast Centers, Inc.”

As mentioned in the recent post, "Scrapping the Barrel to Support Health Reform", it seems like the current Health care reform plan is costing the nation a trillion dollars yet is taking away money from preventative care of deadly diseases, mainly its been cancer that has been hit the hardest.

The optimist in me at first said that with these changes, maybe techniques and other medical procedures will be forced to improve based on this change. I still believe this will be the case, but does one outweigh the other? The best approach would be to do both of course. Maintain the guidelines that have been proven effective through various published trials, and allocate ARRA funds to increase R&D of new treatments or improved quality of current techniques. Who knows, there may be money left over from the HITECH stimulus funds by ARRA if physicians are unable to collect the 44k in order adopt EMR.

Once improved procedures allow for a change in the guidelines, then the change is warranted. If not, guidelines should not be altered.

The National Consortium of Breast Centers (NCBC) is currently the largest national organization devoted to the care of Breast Disease. Through their quality measures program, the National Quality Measures for Breast Centers™ (NQMBC™), breast care centers have the opportunity to collect and standardized data to the NCBC in hopes to improve clinical care of Breast Cancer Patients.

Leavitt Out, Drummond In?

As usual, its been a busy few weeks in the Health IT world and things continue to get shaken up with many recent announcements.

In a press release on 10/22/2009 the Certification Committee for Health Information Technology (CCHIT) announced that they are seeking candidates to serve as Trustees and Commissioners.

Another press release on 11/13/2009, announced that CCHIT's well known Chair, Mark Leavitt will be retiring in March of next year after 5 years of service.

Once the first press release came through on my feed, I thought it was only a matter of time before this happened. Changes need to be made by the CCHIT to gain acceptance by many skeptics. Then I received the second feed, an interesting decision made by Dr. Leavitt to announce his retirement, especially since the CCHIT has been under major scrutiny lately for being the sole certifier of EMR systems and carrying a rather large price tag, so large in fact that most of the smaller vendors are unable to afford the certification. I'm just not sure if leaving his organization now, especially announcing it, was the greatest business decision for the CCHIT.

The CCHIT has also been accused by it's critics for catering to the larger EMR vendors that also conveniently sit on their Board of Trustees and Commissioners.

I find it quite coincidental that after undergoing such a large amount of scrutiny for favoritism that the CCHIT is now holding interviews to replace some of it's Board Members. I know that you are probably thinking, damned if you do damned if you don't. Thats not where I'm headed. I want to give kudos to the CCHIT and Dr. Leavitt for their accomplishments in the past years as well as the realization, or wake up call, that changes need to be made their board, specifically the board member ratio, which I'm sure will be affected. The positions are open to members of physician practices and hospitals, payers, health care consumers, vendors, safety net providers, public health agencies, quality improvement organizations, clinical researchers, standards development and informatics experts and government agencies. I would imagine that the vendor to healthcare provider ratio will be severely affected.

As for Dr. Leavitt leaving, personally I don't think this is the greatest time the CCHIT during this critical time, especially when the certification business is open for business according to Health and Human Services. Who know's, maybe its a career move...he would be a perfect candidate to head up a start-up certifying company.

That brings me to my next topic, the Drummond Group may prove to be a worthy alternative. They had their own press release on 11/02/2009 that they will submit to become a certifying body. I haven't heard of any progress, but if anyone out there has heard anything, please let me know. For those of us who are new to the Drummond Group, they are a company specializing in interoperability testing. Rik Drummond, CEO of Drummond Group was quoted in the press release saying, "Drummond Group has been supporting Fortune 500 industries and government by certifying the transfer, identity and cybersecurity of their internet information flow over the last ten years. We have also done testing for the CDC, DEA and GSA. Certification of EHR is a natural extension of our testing program, and we believe we can provide great value for the medical community. We look forward to the publishing of the ONC requirements in the days ahead so we can get started."

There seems to be a lot of progress within the Certification realm. My only other questions and worries are targeted towards getting everything in place in time for physicians to get their reimbursements.