May 14, 2009

More vested interest vilification of virtual colonscopy decision

The Colon Cancer Alliance has distributed a statement of disappointment over Medicare’s decision not to pay for virtual colonoscopy.

Let's do a reality check on what they say in that statement.

"This decision now leaves millions of older Americans exposed to a higher risk of colon cancer.”

• Nope. Not one bit higher than it was the day before the decision was made. The risk is the same. Ridiculous fear-mongering rhetoric.

“It also exacerbates an unequal standard of care between Medicare beneficiaries, who do not have the choice to undergo a virtual colonoscopy, and those with private insurance who do.”

• Euphemism for rationing – battle cry of almost any anti-health care reform movement.

"By denying coverage for virtual colonoscopy, CMS is sending the signal that increased screening amongst the Medicare beneficiary population is unimportant.”
• Hmmm. I didn’t get that signal at all. I heard a signal of “show me the evidence in a Medicare population.” Period. There's no denial of payment for methods WITH solid evidence in a Medicare population.

By the way, the Colon Cancer Alliance is sponsored by a host of drug companies and by GE Healthcare, which makes and sells virtual colonoscopy machines.

Let's be clear: I don't have a dog in this hunt. I have nothing to gain or lose by Medicare's payment decisions - no more than any other taxpayer. But I can't stand the rhetoric. And I'm going to write about it whenever I have the chance.

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May 08, 2009

TV networks ignore health story costs and evidence

Bad week on network TV.

Stories on...

a male contraceptive

robotic surgery

a new MRI device

* and a new skin cancer detection device

all failed to discuss costs, to quantify benefits and harms, or to give independent perspectives.

Viewers of these programs got one-sided, incomplete, imbalanced portrayals of health care treatments, tests, products and procedures.

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April 20, 2009

The virtual colonoscopy conundrum

Good LA Times piece: "Virtual colonoscopy at center of policy debate: Will Medicare pay for the procedure even though there's no consensus about its effectiveness?" Excerpts:

In an extensive, year-long, review of virtual colonoscopy, Medicare officials scoured medical journals, convened doctors and health policy experts and reviewed more than 400 opinions submitted in two public comment periods. colo-ct-082.jpg

Though many urged Medicare to cover virtual colonoscopies, others counseled caution.

"You have to be really, really careful when it comes to preventive services because you are starting with asymptomatic people who appear to be healthy," said Dr. David Shih, senior director of medical affairs at the American College of Preventive Medicine.


On Feb. 11, the federal agency drew a simple conclusion: "The evidence is inadequate." It recommended Medicare not cover virtual colonoscopy.

The move sparked an immediate backlash.

"There are those who believe we have to have absolute gold-plated evidence to OK a procedure," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society. "But the fact is that we are not getting the job done when it comes to colorectal screening. . . . We have an obligation to give the benefit of the doubt to Medicare beneficiaries."

Working with a Washington lobbying and public affairs firm, interest groups organized a briefing last month for lawmakers in the Capitol.

More than 50 members of Congress mounted a letter-writing campaign to the Medicare agency.

To some health policy experts, that kind of political pressure is one of the reasons the nation's healthcare system has become so inefficient. Few expect it change, however. .

"The issue is: Who is going to make the decisions about what we do and what we don't do in medicine," Lichtenfeld said. "Let's not kid ourselves: That is a political question."

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April 01, 2009

MD editorial: I probably have prostate cancer but almost certainly won't die from it

See Gil Welch's thoughtful opinion piece in the LA Times.

His conclusion:

"There is no imperative to be screened, or not screened, for prostate cancer. The only imperative is that men be informed about the consequences of either choice."

It's interesting how evidence-based arguments never try to steer a screening decision one way or another - just toward informed decision-making. Yet crusaders tend to push for only one way - screen at all costs.

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March 18, 2009

Another major trial raises questions about the value of prostate CA screening

For years I have tried to reach journalists who unquestioningly promote prostate cancer screening in all men 50 or older - some have promoted it in all men even 40 or over. But the National Cancer Institute trial - the results of which were published today - shows that questions must be asked.

Read the study.

Read the news release from the National Cancer Institute.

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March 17, 2009

Here come the lobbyists - a hint of what health care reform faces

CQ HealthBeat reports that more than 40 members of Congress have signed a letter asking Medicare to reverse its tentative decision to end coverage for virtual colonoscopies, or CT colonographies. Last month Medicare announced its decision citing a lack of evidence that virtual colonoscopies result in improved health for Medicare beneficiaries who do not have symptoms of and have average risk for colon cancer.

This is what's going to happen at every step of any serious health care reform discussion we have in the next few years - or ever. Evidence-based decisions will be labeled as creating rationing. Government officials will be accused of practicing cookbook medicine. Critics will ask consumers, "Do you want long lines like they have in the UK and Canada?"

What fun this will be.

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March 12, 2009

Today Show tries to atone for past sins on screening info

I will give the NBC Today Show some credit for trying to address the issue of too much cancer screening and the overtreatment that results.

Matt Lauer acknowledged that the segment would counter much of what the program had told viewers over the past 10 years or so. What he didn't say is that the questions about cancer screening are NOT new and that the Today Show had actually misinformed viewers in many of their earlier messages.

But despite the good effort, today's program was given too little time, was too loosely organized, and probably left viewers horribly confused.

Thank goodness they had one of the best evidence-based minds on the set to address the topic - Dartmouth's Dr. Gil Welch.

Lauer half-promised there would be more segments in the future on this topic. I hope they live up to that.

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March 03, 2009

Proton promotions

Journalists can set the agenda for public discussion on health care reform. Or they can simply be led by the nose by special interests down a path of the medical arms race.

The latter was the case with a Columbus Dispatch story last week. It was a shill of a story and it should have done so much more to inform readers.

The story was about one Ohio man having to go to Florida for proton beam therapy for prostate cancer. But the story seemed to promote the plans for two proton beam facilities of their own in the near future right there in central Ohio so no one would have to travel to Florida anymore.

Our review summarized:

"Cheerleading hometown story, perhaps meant to pave the way for two very expensive proton therapy centers in Central Ohio. No hard questions about whether two are needed, or about the therapy itself.”

Here's a website promotion for the Florida proton center the Ohio man visited.

UFL proton website.png

The story could have asked for evidence on the benefits the website promotes. And for evidence on the "harder on cancer, easier on you" claim.

Indeed, the Boston Globe this week looked for evidence and reported:

"...a study found that though proton beam therapy is at least five times as expensive as other forms of radiation, only a few small, brief studies have examined its effectiveness. There was no evidence that it was better at curing prostate cancer, and insufficient evidence that it was superior at preventing side effects."

The Columbus paper could have asked questions that appeared in a New York Times story about 14 months ago. Excerpt:

“Some experts say the push reflects the best and worst of the nation’s market-based health care system, which tends to pursue the latest, most expensive treatments — without much evidence of improved health — even as soaring costs add to the nation’s economic burden.”

“There are no solid clinical data that protons are better,” said Dr. Theodore S. Lawrence, the chairman of radiation oncology at the University of Michigan. “If you are going to spend a lot more money, you want to make sure the patient can detect an improvement, not just a theoretical improvement.”

Meantime, here’s an ad one medical center is running in local papers in advance of their acquisition of a proton beam facility.

Proton ad.png

Questions consumers might ask:

1. How can you know you’ll treat 2,000 patients a year when it hasn’t even opened yet? How can you know this will be their choice? Or that it will be the best option for 2,000 a year?

2. Why doesn’t the ad mention any evidence of benefits or harms?

3. Why doesn’t the ad mention cost?

The stimulus plan contains more than $1 billion in funding for "comparative effectiveness" research and guidelines. It is predictable that some in the medical arms race industry will scream "rationing" when questions about evidence and cost-effectiveness arise. Rather than "rationing" journalists could start talking about "rational" health policy decisions. And it starts on the local level, questioning whether any one area needs two - or even one - proton beam facility.

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February 25, 2009

Lack of strong evidence for most heart therapies

Ron Winslow has an important piece in the WSJ today based on this week's JAMA study:

Tricoci P, Allen JM, Kramer JM, et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 2009; 831-841.

Winslow's lede:

Heart disease is among the most studied illnesses in all of medicine, yet just 11% of more than 2,700 recommendations approved by cardiologists for treating heart patients are supported by high-quality scientific testing, according to new research.

About half the medical recommendations for heart patients have limited scientific backing, according to (the study). Instead, they are based mostly on expert opinion -- subjective viewpoints where consensus is often lacking.

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