Wax On, Wax Off
One of my all-time favorite films was the 1984 version of The Karate Kid. In
One of the most complex medical challenges policymakers face is when and how much to pay for treatments and screenings for cancers. Screenings and treatments are extremely expensive, and, while they allow for earlier detection and potential treatment of cancers, they are also very costly and have a high degree of unreliability.
As non-medical professionals, we tend to believe that diagnostic tests like mammograms and biopsies are clear and definitive. The reality is much complex:
- Biopsies indicate the presence or absence of cancer cells in the tissue samples taken. Whether there are cancer cells in tissues not subject to sampling is unknowable unless there are other ways to detect their presence. Moreover, biopsies only indicate that cancer cells are present, and like a snapshot taken at a point in time. They do not indicate whether the cancer is growing.
- Mammograms also have reliability issues. To some degree, radiologists miss indicators of cancer cells, and also, sometimes, have the problem of “false positives,” that is, a mistake is made in diagnosing someone with cancer when they have no cancer cells present. Similar to biopsies, mammograms can only tell doctors and patients whether cancer cells, not whether those cells will grow over time.
In a newsletter entitled “Medicine for People” published by the Monroe Street Medical Clinic, the authors correctly point out that there are many non-aggressive breast cancers with which women can live for decades. As they point out, “the most common form of cancer detected by mammography is ductal carcinoma in situ (DCIS). This is a cancer confined within a milk duct within the breast.”
They go on to cite research studies in Tennessee and Italy that checked on the progress of women found to have DCIS cancer in the 1950’s and 1960’s. The studies found that while 10-30% of the women progressed to later stage cancers, 70-90% did not. The authors’ concluding paragraph states:
“DCIS cannot be ignored. Current medical knowledge makes it difficult to determine whether a particular woman’s cancer is going to be quiescent or aggressive. However, in treating DCIS, both a woman and her physician should be aware that DCIS may not require radical treatment.”
Having seen many examples in which medical science has not progressed far enough to determine whether someone has a particular condition or what its progression might be, I was excited to read an article in the Sunday, August 30,New York Times, entitled “Beyond the Biopsy: A Tiny Monitor for Cancer Reporter Anne Eisenberg reports on research at MIT through which the researchers have created prototypes for cancer monitors the size of a grain of rice. These monitors, according to Dr. Michael Cima, the lead researcher, can offer continuous information about changes in tumor size and behavior. Although these particles have only been tested in mice, they present an opportunity to change fundamentally the way in which we manage progressive diseases like cancers.
If we use the example of prostate cancer, the “watch and wait” strategy costs very little, compared with prostate surgery or radiation beam therapy. This kind of monitoring, coupled with alternative treatments like diet, exercise, and stress reduction, as recommended by Dean Ornish in his ground-breaking study published a year ago, would significantly reduce the cost of disease treatment.
In my last blog, I raised the question about government-managed programs. Ask yourself the question: if this monitoring system were to reach a point of being proven, who is more likely to implement it faster, a Kaiser-Permanente or Medicare and Medicaid? The answer is that the private sector provider or insurance plan, freed from the need to go through an elaborate and time-consuming public comment process, and freed from artificial annual budget constraints imposed by government spending caps, is far more likely to adopt this kind of technology sooner, since it saves money.