IT HAPPENS EVERYWHERE

October 13, 2010 — Routine cancer screening has become so deeply ingrained in medical culture that even patients with advanced cancer continue to have these tests, even though they are unlikely to benefit from them.

This is a "clear and compelling" example of wasteful care, say researchers reporting the finding in the October 13 issue of the Journal of the American Medical Association.

In the study, Camelia Sima, MD, MS, from the Memorial Sloan-Kettering Cancer Center in New York City, and colleagues identified 87,736 Medicare patients 65 years or older who were diagnosed with advanced cancer. These cancers (lung, colorectal, pancreatic, gastroesophageal, or breast) are associated with a median survival of less than 2 years.

The researchers then investigated the use of routine cancer screening tests in these patients, and found that:

* 1.7% had undergone a lower gastrointestinal endoscopy
* 15% of men had a prostate-specific antigen test
* 8.9% of women had a mammogram
* 5.8% had a Pap test for cervical cancer.

"A sizeable proportion of patients with advanced cancer continue to undergo cancer screening tests that do not have a meaningful likelihood of providing benefit," the researchers conclude. These rates are likely to be higher among young cancer patients who are commercially insured, they add.

Clear Case of Wasteful Care

"We have identified a very specific circumstance in which the case for wasteful care is . . . clear and compelling," Dr. Sima and colleagues write.

Although any attempt to place restrictions on care is routinely met with vocal opposition and accusations of "rationing," this particular instance of curbing cancer screening for patients who already have advanced cancer is "likely to be relatively uncontroversial," they note. It would likely have only a small impact on the whole Medicare budget, but employing this paradigm across other diseases and conditions would "systematically improve the value of each Medicare dollar spent."

"Each medical specialty needs to engage in thoughtful self-scrutiny to identify episodes of unnecessary care," Dr. Sima and colleagues write. "We suggest that the road to a high-performing, high-value healthcare system will be paved with small stones such as the example we have identified."

Explanations Include "Autopilot" Culture

"The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits," Dr. Sima and colleagues write.

"Patients and their healthcare practitioners accustomed to obtaining screening tests at regular intervals continue to do so, even when the benefits have been rendered futile in the face of competing risks from advanced cancer," they write, referring to a "culture of screening on 'autopilot'."

As a case in point, they refer to a study that found continued Pap screening for cervical cancer in women whose cervix had been removed (JAMA. 2004;24:2990-2993).

They also identify another potential cause — a lack of communication between oncologists and/or primary care practitioners and their patients. In particular, there is an avoidance of "the difficult discussions," in which the physician should explain why a procedure that the patient has become used to undergoing regularly is no longer needed, they suggest.

"There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and many patients use denial as a coping strategy to face impeding loss," the researchers write.

"Our findings represent one manifestation of this communication deficit," they conclude.

The study was supported by a grant from the National Cancer Institute. The researchers have disclosed no relevant financial relationships.

JAMA. 2010;304:1584-1591.