WGBH Radio; The Callie Crossley Show

I'm Cally Crossley This is the Cali Crosland show. We continue our health care coverage with a look at the fine line between preventive medicine and over diagnosis. The standard operating procedure in modern medicine is the early diagnosis. The theory is to keep people healthy by determining whether or not they have a medical condition. The practice is to find these conditions early on through screening. This precept is one that appeals to most people. Isn't it better to be screened for a disease now rather than treated for that undetected disease later. But at what point is that diagnostic probe screen and scan too much. Do they come with their own set of risks. How can doctors balance preventive medicine with invasive costly and at times unnecessary procedures not to mention the stress that comes with the threat of being sick. Up next the doctor will screen you now. First the news. From NPR News in Washington I'm Lakshmi saying the U.S. Supreme Court hears

arguments this hour on a provision to expand Medicaid under the federal health care law. It is an extension of the issue at the heart of the debate these past three days whether the mandate to have health insurance is constitutional. Earlier today justices question whether all of the law must be struck down if the coverage requirement is invalidated. NPR's Nina Totenberg says Justice Ruth Ginsburg said there were many things in the law that had nothing to do with the mandate. She says so why shouldn't we say it's a choice between a wrecking operation and a salvage operation. And the more conservative choice is a salvage operation where we preserve as much as we can and we'll be able to Congress decide what it wants to change keep or discard whatever. NPR's Nina Totenberg speaking of Justice Ruth Bader Ginsburg at the U.S. Supreme Court. NPR series a Thomas Sona reports protesters outside the court are trying to offer their final say on the matter.

The crowd outside the U.S. Supreme Court was the smallest bet all week but that didn't stop protesters and supporters of the law from trying to drown each other out. Susan Clark is the one ringing the bell. She's dressed as a Native American just like the original Tea Party members did in 1773. You know the ones that know that. We'll have more on. For much of the morning Clarke rang her bell to muffle the voices of activists shouting protect our care protect the law and as supporters of the law announced they were done rallying for the day. Clarke told them to go to Cuba and find free healthcare there. Teresa Thomas Soni NPR News. Outside the Supreme Court in Havana mass in the shrine of the Cuban Revolution attended by hundreds of thousands of Roman Catholics today as Pope Benedict the 16th presided. Benedict was due to meet with former President Fidel Castro with whom he was expected to raise a number of issues such as human rights. President Obama's health care law is not the only top issue before the Supreme Court but on the Republican presidential campaign trail as well NPR's David

Schaper reports from Sparta Wisconsin that former Pennsylvania Senator Rick Santorum is trying to close ground on front runner Mitt Romney at a campaign stop in Janesville Wisconsin Santorum ask this question if it is a top priority for Republicans to repeal President Obama's health care law then why would we nominate someone who is uniquely disqualified to make the argument. Santorum says Mitt Romney enacted the same kinds of mandates to force people to buy health insurance in Massachusetts that President Obama signed into law for the country. Santorum adds that the only way for Republican voters to provide a clear convincing mandate to repeal the health care law is to nominate him for president. David Schaper NPR News in Sparta Wisconsin. At last check on Wall Street the Dow was down more than 80 points. This is NPR News. And from the WGBH radio newsroom in Boston I'm Christina Quinn with the local stories we're following. The MTA is recommending an average 23 percent increase in bus and subway fares and some

service reductions under a scaled down plan to close the transit systems deficit. The fare hikes outlined today are less drastic than earlier scenarios. The plan also relies on legislative approval of about 60 million dollars in one time aid under the final proposal fares for passengers using Charlie Cards would rise from the current 125 to 150 for buses. And from 170 to $2 for subways. The plan would save most weekend commuter rail service and ferry service. Both had earlier been targeted for elimination. Some bus routes would be eliminated or modified. Cambridge police are warning residents to be cautious after two women were robbed in assaulted early this week. Both women were wearing headphones at the time of the assault. The Boston Globe reports that police are warning women not to listen to music when walking alone at night and to walk with friends as much as possible. Court documents say a Vermont snowplow driver and his wife lured a beloved prep school teacher from her home by pretending their vehicle had broken down and they needed help and then strangled her before throwing her body in the Connecticut River. Allen Prue and his wife Patricia Prue were arrested early today and are facing second degree murder charges.

The New Hampshire House has voted to form an interstate health care compact rejecting an effort to instead study the cost implications for New Hampshire if the state assumed control for health care within its boundaries. The bill proposes that New Hampshire join with other states in delivering health care to its residents. In sports the Utah Jazz are in town tonight to play the Celtics. And right now we have overcast conditions in Boston with a temperature of 46 degrees. We can expect the overcast conditions to continue for the rest of the day showers are likely for the rest in the later on the afternoon with highs in the lower 50s tonight mostly cloudy with a chance of showers lows in the lower 40s. There is a mostly cloudy with a chance of showers temperatures in the mid 40s right now 46 in Boston 48 in Worcester and in Providence Support for NPR comes from America's Natural Gas Alliance supplying domestic energy while working to protect the environment. Learn more at us. The time is one of six. Good afternoon I'm Kelly Crossley this week the Supreme Court justices have been hearing oral arguments challenging the constitutionality of the Patient

Protection and Affordable Care Act. As part of WGBH its focus on health care. We're continuing our health care conversations. Today we look at what could be a side effect of 21st century medicine. Over screening and over diagnosis. Joining me to talk about the fine line between preventive medicine and Too Much Medicine Is Dr. H Gilbert Welch. He's a professor of medicine at the Dartmouth Institute and author of Overdiagnosed Making People Sick in the pursuit of health. We're also joined by bioethicist Art Caplan in June he will be head of Bioethics at the Language School of Medicine at New York University. Welcome to you both agreed to be with you. DR. Let me start with you. Let's put us all in the same page. Define overdiagnosis. Sure. Let me just start by saying I'm a conventionally trained physician I teach I do research I see patients and I believe that American medicine can be very beneficial for sick patients. My concern is about what we're

doing to people who are well and over diagnosis occurs when we doctors make diagnoses in individuals who are not destined to ever develop symptoms or die from the condition diagnosed. And it's a side effect of our relentless desire to try to find disease early and that's through annual checkups and screening. And the problem is that we all harbor abnormalities and our tests are increasingly able to see them be they looking for genetic aberrations or biochemical aberrations or structural aberrations that we can see on imaging scans. Yet most of these abnormalities will never go on to cause disease. But as doctors we don't know which will ever matter and which won't so we tend to treat everybody. And that means we're treating people who cannot benefit because there's nothing to fix. But these people can be harmed. And that's the problem as we have all this

technology that can detect abnormalities more and more of us have them and a certain fraction are being treated for things that was never get where that was never destined to bother them. So Dr Well since you as you've said you were a conventionally trained doctor. What prompted you to look at this. Because I would imagine that most of the conventionally trained doctors are if not over diagnosing they're certainly doing the preventive screening and probably a lot of it was there some specific occurrence that made you think we need to examine this a little bit more closely. Well I should say I'm 56 years old and so I went to medical school getting on toward thirty years ago and I have seen just a tremendous change in our profession from the focus on the sick to seeking early diagnoses in the well and I've always wondered whether that was. Uniformly The good thing that everyone was suggesting it was and I have become increasingly

concerned that we're getting distracted as physicians away from the sick and putting way too much effort into finding things wrong with well people and I'm genuinely wary that that's actually not a good thing for a health care system to do. Obviously there's nuance here there's no one rule that fits all but the general tendency I think is for us to be too engaged in the well population because that's a population that is hard for us to make better but it isn't too hard for us to make them worse. So we have to be really really careful when we're dealing with people who are healthy. Art Caplan you've heard Dr. Welch talk about his concerns about the two sides to this story of preventive medicine. But you know all of us patients have been Turner potential patients have been told preventive preventive preventive and that keeps you from being sick later and that's a good thing. So I'm wondering how preventive screening and even too much of it can lead to some ethical concerns.

Well I have a lot of sympathy for Dr. Welch's view. Let me try and draw one ethics distinction between prevention in terms of lifestyle and healthy habits and prevention in terms of diagnostic screening. We're told not necessary to go out and get screened every day. What we're told is live a life that has balance. Live a life that has good health habits that will get you healthy or keep you healthy. Screaming on the other hand as Dr. Welch rightly points out can detect all kinds of anomalies. Outliers. Differences. You know it's like measuring the population thing. My goodness some of us are seven feet tall. What does that mean. Is that bad and that is it. Is it bad to be unusual in that sense or in other circumstances when we have more and more diagnostic technology coming on there are plenty of people who make that technology want to sell it to us I think. Here let me let me just give an

example to be concrete. If we went up on the internet we'd see all kinds of companies touting genetic testing you probably see this yourself. Yes send your spit in a cup to us and we'll send you back a printout. Right. All kinds of risk factors that you might be at risk and there are companies I will name names like 23 and B have it you know makes it to code me and then there are a slew of even weirder ones who are kind of out of the frontiers of let's call it spin Olympics. They they want to do genetic diagnosis on you. OK well there are some things that they can see that are major risk factors but a lot of the information that comes back is kind of small increases in risk. We don't really know how accurate the testing is. They're making lot of money doing the test and then if you said well what can I do to diminish the risk you're likely to get back at a place like this. Lose weight exercise more sleep board drink less alcohol wear helmet when you ride a bicycle or motorcycle get more stressed out of your life.

And guess what you need to do the tests you can do all these things. Spending a thousand dollars or the genetic test. So that's what I mean when I say there's a difference between promoting diagnosis promoting preventive screenings versus trying to figure out how to get. People change. Well that the way you explained it makes perfect sense of a doctor well to know people are listening thinking. I have spent my entire life if I am a woman being told to you know get a mammogram or get some kind of screening test that will help me. If cancer is detected the earlier the better. In fact as I'm sure you know when the rules were changed and there was an adjustment made to this to say that well maybe now you have don't have to get it every year maybe every other year and certain people certain age groups can you know wait even longer. There was an outcry because a lot of women

rightly so I would think were afraid of I don't want to be the one that's not screened early and get cancer. Well let me first reinforce what Dr. Caplan said and because he's absolutely right the questions we're raising here has nothing to do with about health promotion efforts to do what your grandmother it's told you to you know eat it don't smoke eat your fruits and vegetables go play outside that is still great health advice we're talking about this early detection model and mammography and prostate cancer screening turn out to be just perfect examples of the kind of things that can go wrong. And let me first say that I think as a profession in the public health profession is also part of this. We've sort of systematically overstated the benefits of early detection and we've understated or worse yet ignored entirely the harms of. Early detection and the major harm is over

diagnosis that is being told You have a cancer treated for that cancer. When that cancer was never going to bother you. That means women are undergoing lumpectomies or mastectomies receiving radiation and chemotherapy in some cases for cancers that was never going to bother them and all of a sudden when you understand that there are yes potential benefits but they're small but there are also harms all of sudden you realize wow there's two sides to this story and the place where we as physicians most dramatically learn this sort of the poster child for the problem has been prostate cancer screening. When 20 years ago a simple blood test was introduced a quote simple blood test because it was easy to do although it raised some of the most complex issues in medicine. And 20 years later about a million American men have been treated for cancer that was never going to bother them. The test was the PSA. It's able to detect minute quantities of something called

prostate specific antigen minute meaning one billionth of a gram we have very capable tests. But it turned out a lot of men had abnormal PSA as many more then would ever suffer from prostate cancer. Yet many of them had minute prostate cancers and all suddenly realize oh yes some men die from prostate cancer but many more die with prostate cancer. And we introduced this diagnosis to a million new men. Does it matter Sure it does. Most were treated with either radical surgery or radiation and roughly a third suffered long term side effects of treatment generally related to bowel bladder or sexual function and a few have died in the process. That's the reality of early detection. Yes it may help some but it also harms others and I don't think we've been as clear about that with the public as we should be. Dr. Welch I should give you an opportunity to say that you practice what you preach with

regard to the diagnostic diagnosis of prostate cancer or the or the preventive screening as it were. You mean I have not had a PSA nor do I want one. I think it's an awful deal. I think the U.S. preventative health services for task force did the country a favor in clearly being clear they do not recommend this test. I think as it stands now this test is a bad deal for patients. What do you say Art Caplan though to those patients who you know Dr. Welch has made the very cogent rationale for why patients are not getting the benefit of it. It's really hard if you have prevention in the same sentence with BET. And it just doesn't seem to go well if you're right and your example of mammography not being necessary and you will want to be for women 40 to 50 is the absolute paradigm

case of this we told women when for I don't know 30 years the virtuous thing to do the right thing to do is to take your health and get in there and get that mammogram. And then one day we look at the evidence carefully and say whoa getting all this radiation that might not be too good for you age 40 to 50 by having a lot of false positive growths and since and who knows what that show up in breast. That's a lot of tests. Maybe surgical procedures in any way the yield of the lives saved. Turns out to be far less than we would have thought. I'll make two conclusions about this. One evidence which we're all obsessed with in medicine which is the health reform legislation survives. There's a lot of. Betting that getting more evidence will help us contain cost evidence is great. But I'm here from the ethics side of the street to say as evidence of all you've got to attend to the Borel message. What I mean by that Cali is if I tell you it's

virtuous and good to take responsibility for your health by getting preventative screening then I start to find out that some of the screening has a downside as Doctor well to say I've got to attend to the moral advice I've been giving and say you know what you did do the right thing you did do a good thing but we're just getting more evidence now that there's more risk associated with our testing than we thought. If you don't manage the risk you will end up where we are today in terms of the moral message. Women are still getting their money. From 40 to 50 interleave the evidence went out the window. You know the president's wife said I'm still going to get this. Secretary the billions for post in Human Services did not forget that evidence it's still good. Other people said well work it out with your doctor. So we have to manage the ethics of personal responsibility of what we consider. Virtue but the part of the patient along with information about the tests and expand this even further and say when you talk to a doctor and I haven't had the prostate test either for exactly the same reason the doctor welts is talking about

it has to be acceptable to make the decision to say you know I'm going to forego that test if I'm not being bad I'm not being reckless and let the responsible kind of listen to this. You're not going to take that much disease. But there's a pretty good chance you find something slowly growing in me and you could wind up giving me an operation that makes me into dinner incontinent or just kills me from the operation from an infection or something. I don't think I want it. That isn't bad. In other words you've got to give exculpation to pee. People who say no to certain types of screening managing the ethics in an era of many many tests available to all will continue to talk about what that means. We're talking about over screening and over diagnosis. At what point does preventive medicine become too invasive and too frequent. You can join the conversation at 8 7 7 3 0 1 89 70 8 7 7 3 0 1 89 70 has early detection saved your life. Do you feel like you're

subjected to too many tests. Would you prefer more time with your doctor and less time with the machine. 8 7 7 3 0 1 89 70 8 7 7 3 0 1 89 70. You can write to our Facebook page or send me a tweet at Kelly Crossley. We were listening to WGBH Boston Public Radio. We love our contributors. That means you. And Bank of America are lending and investing to help strengthen local communities and support the people who call Massachusetts home. For more information you can visit them online at Bank of America dot com slash Boston. And new rep theatre presenting Long Day's Journey Into Night. Eugene O'Neill's Pulitzer and Tony winning American masterpiece about family addiction and life's

emotional struggles. April 1st through twenty second tickets at new rap dot org. And for members of the Great Blue Hill society who's a state and planned giving arrangements to WGBH create a lasting legacy and ensure public media for generations to come. What will your legacy be. Playing with the next FRESH AIR conductor Michael Tilson Thomas tells us about his new PBS special celebrating his grandparents Boris and Bessie Thomashefsky pioneers of the Yiddish theater. The show features music from the Eddas stage also a former sports agent comes clean on the dirty business of college football. We talk with Joshua Lux about his new memoir. Join us. This afternoon at 2:00 here on eighty nine point seven. WGBH. I'm Brian O'Donovan. Join me and singer songwriter Robbie O'Connell for an Irish soldier this September. It's a 10 day tour through the southern countries are violent. We visit ancient burial mounds and majestic castles traverse the wonderfully named mountains. Visit

Dublin and Kilkenny castles and enjoy nightly music sessions. This trip with an up fast and you won't want to miss out. To register visit WGBH dot org slash learning tours. This week WGBH focuses on health care. We inquire into whether we are overdiagnosed local impact of a national issue. Hear the reports all this week here on AB 9.7 WGBH Boston Public Radio. Welcome back to the Calla Crossley Show. If you're just joining us we're talking about health care with a focus on overdiagnosis and overtreatment at what point are perfectly healthy people made sick by too many diagnostic screens probes and scans. I'm joined by Dr. H Gilbert Welch he's a professor of medicine at the Dartmouth Institute and author of Overdiagnosed Making People Sick in the pursuit of health. We're also joined by bioethicist Art Caplan

in June he'll be head of Bioethics at the Langan school of medicine at NYU. You can join the conversation at 8 7 7 3 0 1 8 9 seventy 8 7 7 3 0 1 89 70. Do you think you're getting too many tests at the doctor's office. Are you willing to forgo some tests and maybe take your chances thinking that you know it's not quite necessary. 8 7 7 3 0 1 89 70 8 7 7 3 0 1 89 70 and you can send me a tweet or write to our Facebook page. And we do have a Facebook comment. Erica writes tests are deemed unnecessary that's in quotes only when they don't pin down the problem. Years ago my very thorough intern is often ordered to Minnie in an attempt to find the cause for an unusual symptom. I still have serendipity to slee I can really can't talk today and differ. Really very early endometrial cancer was discovered and cured entirely by a hysterectomy. No chemo no radiation. Shortly after my surgery I read a New Yorker

article explained that there are cases in which cancer is detected early but not treated never progressed enough to cause illness. I wondered briefly if I had gone through a prolonged recovery due to surgical complications. For nothing but quickly realized I would not have chosen to roll the dice that my cancer would not have progressed. So Dr. Welsh I'll get you in our campaign to respond to that. Well this is I think a variant of I'd rather be safe than sorry. Kind of understandable. The approach that some people take to the problem I think one of the things that people need to understand it's not immediately clear when we're looking for early forms of disease which is the safer strategy. We now know at least six cancers can be over diagnosed and few find early forms that will never progress to her patients you don't know which they

are so you go ahead and you treat them all. And so now we're set with this sort of balancing act between maybe helping some but treating others unnecessarily. There is harm from treatment. All of our treatments have harm. Usually when you're symptomatic and you have real problems you know you those risks are totally reasonable to accept. But when you're well the balance is much finer and so I think one of the messages here is that there are two sides to this issue you can yes you might miss a benefit to be helped but you also have this problem if you look for disease early that of unnecessary treatment and being harmed by that treatment let me give you some sense of that tradeoff in the tests that you brought up which is mammography and this is my best sense of the current data that you have to screen about twenty five hundred women 2500 women. For a period of about 10 years from age

50 to 69 once each year to help one avoid a breast cancer death that's a good thing. But it's only one of that two thousand five hundred women and I think one of the things we need to begin to pay attention to is what happened to the other two thousand four hundred ninety nine in this country somewhere around a thousand will have at least one false positive result they'll be worried that they have cancer they will be very nervous by it. They will be told that they don't have cancer but many are still told that they have something abnormal they have displays or atypical findings and they're left worried about their breast. That's a problem most people are aware understand that false positive problem from screening. But then in addition to that somewhere between 5 to 15 will be treated for cancer that was never going to bother them they'll undergo a mastectomy or a lumpectomy have radiation and or chemotherapy. Now I can't tell you the right

thing to do. All I can say is that's a close call. And we ought to tell people both sides of the story I think the ethical obligation I think Dr. Caplan would agree with me is tell people the deal they're getting into. And in the case with mammography we really haven't been able to have that balance discussion. The efforts to promote it have been not only that it's been the right thing to do that's been to scare women it's been to coerce them. In fact the original sort of publicize the surrounding mammography included an advertisement that you know if you haven't had a mammogram you need more than your breast exam and well that's saying you're crazy if you haven't had a mammogram. I think women who want to undergo mammography should continue to do so feel good about it I also think women who do not want to should feel equally good about this is a genuine choice. Art Caplan I want you to respond to that Facebook message and then to Dr. Welch as you know talking about the flaws. Better safe than sorry. Motivation and this is

not a perfect analogy under any circumstance because I don't think you can compare health to anything else. But it reminded me of going to take your car in for one thing. You get in there and then they go you know. Well there's also this and this and this and this and you know OK maybe it is a false positive but you don't want to be driving down the road not knowing that this and this and this is going to you know fall off the car. So there you are. We just had to give an example of this. Listeners are like we just had a gentleman come in to our Huntington's disease clinic and get screened to find out if he was at risk of having inherited the gene that causes that. I got a phone call and they said you know we got an issue here. He's not at risk. And they said oh OK. Rarely do people call me with nothing to news and say we you know a person is not going to get the disease because that you know the reason is we looked at this test and that's about as far as it. So you could find all kinds of incidental things out screening some are good news some are going to let you jump in there and say whoa there's a pancreatic tumor we would've found that

but now that we're in here we can see it. There are certainly people who are going to be cautious. There are people going to be risk avoiders So I think what Dr. Wilson are saying is the message isn't just that screening is always a good thing or a mandatory thing or a virtuous thing. It is something that frequently carries risk. Maybe it's not an accurate test. Maybe it'll produce incidental findings like my friend with this funny to disease that you're not necessarily so. In finding it. Maybe it isn't clear we're going to do about it anyway so I might be able to take a picture of your head and say you have early onset Alzheimer's and that might give you some relief from saying oh I felt forgetful but there's no cure there's nothing you can do that really aren't an effective medicine. Maybe you don't care for that information even if we had such a bubble you will soon have such a neurological kind of a screen. So you have to have doctor patient relationships the ability to

both make a choice. That is the risk of a leader and a choice the risk tolerance. You have to also make sure that in trying to present information to the patient you know coerce them you know scare them. Let them understand that almost every test has some limits on the fact your AC is going to be some errors. Every test has some ability to pick out disease with a marker or condition or something is there but sometimes that's false when you're getting a false reading. And then in some instances given the course of what might follow there's not much for you to do except make a lifestyle change or whatever which you could do anyway. So we need to enrich the discussion forum consent has to be more tolerant when testing is imperfect which it almost always. If I can give you one more thing let me get it. Call around here and that may afford you an opportunity. Marion from Foxboro Go ahead please you're on the Kelly Crossley Show WGBH

eighty nine point seven. I thank for taking my call. I wanted to say that when I was first pregnant about 13 years ago my doctor wanted me to have an amniocentesis test and that would tell me this but that my baby would get really up with me I wanted to be surprised and I would also tell me of my childhood you know. But then again I didn't want to know. And my doctor was quite shocked. For him it was a routine procedure and I knew that it carried risk death to my baby and I didn't want to have it. And he was quite shocked and I'm wondering how much he maybe understood very testing is driven by the habits of doctors as opposed to the best best known recommended. Thank you for talking to me about what the risk where you were just assuming that I would have the first time I was aware of the way the RAF and I was like oh Mary excellent question. Yes excellent question. Dr. Welch Please address.

Sure First I appreciate Marian bringing up the whole concept of pregnancy because as this is an area where a lot of overdiagnosis goes on and I think a lot of people are wary than necessarily about what should be essentially a normal process in fact there's a whole chapter in my book sort of dealing with some of the issues about pregnancy and over diagnosis Marion's asking you know why why this is happening and it's not a simple answer there are many forces at work I mean one is is money and Dr. Caplan's already mentioned that you know that the truth is. It's a lot easier to expand the indications for a drug or treatment. To a broader number of people than it is to build a better drug or treatment so these are huge markets if people can move into the well population and sell treatments for the well population it's a great way to make money and so there is a strong financial incentive and it's not just drug companies drug companies deserve a fair

amount of blame but it's also our medical centers who recognize that screening is a great way to get new patients and you know if the Trust me on the Otis Brawley now the head of the American Cancer Society once pointed out that the free scree free screening PSA ultimately produced about $5000 in Medicare Billings on average from subsequent biopsies and procedures so money is part of this story. Another part though is true belief. Because that is a habit that Marian was referring to I think it does you know we're just we've all sort of said Of course early diagnosis is always good and in some ways you know I have trouble sort of even articulating that in my own head of course the early days must be good but but it's not always good because it ends up involving way too many people. And then my colleagues would want me to mention lawyers and I think we definitely probably put lawyers on the table where doctors feel they're punished only in one direction they're punished for

underdiagnosis they're never punished for overdiagnosis So it's an asymmetric legal situation and then finally. And I just have to include WGBH in this maybe Cali. You know the media has done a disservice here and part of that is been sort of signing on to you know early diagnosis is always you know sort of an uncritical acceptance of it. And then the appearance of survivor stories you know which are people who've apparently benefited from the process and they're been particularly misleading. You know people with screen detected breast and prostate cancer who say they owe their lives to the test. In fact when you look at the data they're much more likely to actually be overdiagnosed patients and they are patients who've actually been helped by the test and so here we have a harm interpreted as a benefit it becomes a very positive cycle that argues a

pair of peers to argue for more screening because there are more survivors out there. All right. Here's Mike next caller. Tom from Middleton Go ahead please you're on the callee Crosley show. Eighty nine point seven. All right. Oh I'm well I'm one of those people who know my life. My doctor ordered the early screening which resulted in a biopsy. This showed that my old prostate cancer in a couple of the 24 probes all over within four months and I had the I chose at age 62 because I was in good health. If you have the radical prostatectomy and the path ology report indicated at that point that the prostate was fully involved and was approaching the margins. And one would know who was involved. So a year and a half now later unless that prostate cancer

would have quit on its own I wouldn't be here. And I'll take the response off the air thank you. Thanks. How much time are kept in one response. Sure I think that's a great story and I'm pleased that cancer was detected and removed. But it comes back to the Not everybody is going to want to roll the dice in the same way as you get older in terms of thinking about what the odds are of detecting and finding that cancer and the chances of having it removed and not having it kill you. How effective will that be. What the harm would be from having that surgery and then what the baseline rate is of old men myself included who have slow growing cancers that are there but aren't going to kill them until they die of something else anyway. So we need to open the door to different perspectives on risk we need to

open the door to at least some discussion that there might be a downside to preventive screening too early diagnosis. It's not that it's either or. It's that as you understand all the emphasis we put on. Up side the positive side. People need to hear a little bit more about what the down side is about what the error rate is about what the uncertainty is and even about whether the treatments that are taken. What I was going to say for example when women commune recently to what I saw in our genetic screening clinic for breast cancer and she turned out not to have inherited the gene that disposes some women toward early onset breast cancer. This is some listeners will know the BRCA 1 in 2 Gene Gene have. But as she left she said boy I'm glad I'm not at risk. And we were looking at each other saying this woman smokes three packs a day and is overweight and lives downwind from an

oil refinery. You know she didn't get that gene in the screening. As far as it went was accurate but that probably accounts for about 8 percent of breast cancer. Well yeah get some work to do and she left thinking I'm pretty sure despite our doctors trying to tell her that she had other risk factors that that one the matter she didn't have. So again you don't want to get a false sense of security had a positive giving a negative result from certain things when there are other factors that may be much more important and that's where in some ways to have to learn to media bashing here for a second when we can overemphasize the perilous way of genetic testing. We're not talking as much about what you could do in a lifestyle change to manage risk so every time we say red wine is good for you Red wine has been good for you. You know this test is something that you pick up this problem early but we kind of miss the fact that a majority of these contributing factors are probably more within our behavioral patrol than they are within early diagnostic and testing control.

Well let's open the door to a conversation about whether somebody somewhere in the world is doing this better. And can we here in America are we just too tied to these machines. We're talking about health care taking stock of 21st century medicine with a focus on over diagnosis. You can join us in the conversation at 8 7 7 3 0 1 8 9 seventy 8 7 7 3 0 1 89 70. Have you benefited from early detection. Do you feel like you're subjected to too many tests. Are there times when you just like to skip that mammogram or that colonoscopy 8 7 7 3 0 1 89 70 8 7 7 3 0 1 89 70. You can write to our Facebook page or send us a tweet that Callen Crosley. You're listening to WGBH Boston Public Radio. Funding for our programs comes from you and the Harvard innovation lab a university

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more treatment mean better health. Are we looking too hard for disease. You can join us at 8 7 7 3 0 1 89 70 8 7 7 3 0 1 89 70. I'm joined by Dr. H Gilbert Welch and Art Caplan. Dr. Welch is a professor of medicine at the Dartmouth Institute and author of Overdiagnosed Making People Sick in the pursuit of health. Art Caplan is a bioethicist who will soon be head of Bioethics at the language school of medicine at NYU. Join us at 8 7 7 3 0 180 970 8 7 7 3 0 1. Eighty nine seventy Bob from Wickford Rhode Island Go ahead please you're on the Cali Crossley Show. Eighty nine point seven WGBH Hi. Thanks for taking my call. I've had a problem in following this whole issue on prostate cancer screening. It does not make sense to me and what doesn't make sense. Is having the information about what you have. The problem is not in

having the information. The problem is what you do with that information. And and my urologist would say in many cases let's wait and see and follow it. But if you know you have have it and you can follow it and see whether it's fast growing or slow growing then you can prevent the problems you might have. But you don't have to do anything if you know if you know what you're working with. So I'll take the answer off line and like your comment. Thank you. So Art Caplan seems to fall in line with what you're saying too much. A diagnosis. Or rather too much people following through on a diagnosis and not understanding the information you're given from what ever the diagnosis may be. That's right so if you have a good partnership with your doctor and you say well I will take the test and I'm going to watch it over time and see what. The numbers are if they're going up in a steady way visit to visit over a

period of time and getting higher and higher. I know that there may be a baseline of a slow growing problem there but depending on how old I am if I may need to. Maybe I'm not as worried about that as if I'm 50. Maybe I'm not going to do anything about it even though we're monitoring because the rise in numerical test result that indicates a problem is slow. So different people will respond differently to well do I want to then do a biopsy. Do you want to push further to see what's going on and so forth to have a history of prostate cancer in my family and so forth what I will do my negotiating around the information. I know we all want it to be either Yes the test is a test or if. I wish it were that way but a lot of tests just aren't that way and they're going to require different people with different now used to be imaged them and some discussion with your doctor about what your values are you know when you go to the investment counselor type person that usually say your

risk of a leader. I like to gamble and then they kind of say well you know for you maybe investment in this is better than that a little bit of that discussion is what you want to get into. If you have the luxury of having a doctor has some time to explain the test to you which obviously is a cynical way of saying we have another problem with early diagnosis to testing it on a test but we don't have a lot of time paid for with a doctor to talk about them. Can I jump in here just for a second because I think Bob makes a point that I hear a lot in in large part I agree with he's saying the problem isn't the diagnostic test it's the infor it's the way we react to them. And he's definitely right we could react better and take more time and wait wait for things to happen over time. And I think there's a lot of merit to the thinking about that line of reasoning. I think there's one other thing though we have to consider is that we don't want to downplay the impact of the diagnosis

itself and that for many of us in some ways simply getting the diagnosis. It is a major hit. You're being told you have prostate cancer now you're going to watch it and that's uncomfortable for a lot of patients you're told you have breast cancer but now we're not going doing that we're going to watch it. And so in some ways some of the harm has already happened. If we're picking up things that are never going to matter to people and yet we're telling them about it we're going to wear them about it so I think I do think that for some people and I'm one of them you know the the question is best moved upstream given the overall deal here the benefits and the harms. Do you want to even start this process because once you start the process it's awfully hard to stop. Drew from Worcester you're on the Calla Crossley Show. Eighty nine point seven WGBH Hi thanks for taking my call. I work in life insurance and I have somewhat of an unattended consequence of

too much medical testing. The medical information bureau provides information to my industry and back in effect your life insurance rating I have heard tell of people going to doctors just saying oh yeah I had one cigarette yesterday and I'm a. You know I think that they've had in their whole life they shows up at the MIT and so they get classified as a smoker. So what I'm hesitant to have too much test done just because I feel like it could cause me to have a bad reading. That's true not only with life insurance that's also true with health insurance now the Affordable Health Care Acts trying to deal with that problem but. But yes diagnoses matter they matter to both life insurance and health insurers. Let me jump in and say Drew thanks for the call go ahead Art Caplan. Here's an example where some diagnostic screening could really work against a whole group so veterans coming back from Afghanistan and Iraq they get screened for PTSD but it turns out that employers when they

come back because they hear about PTSD are weary of hiring veterans not because any particular veteran has PTSD but they just heard about the screening so much that the whole class of people tends to be treated warily you know as somebody who might have PTSD even though the vast majority of people who don't have PTSD but it's a kind of stereotyping of a group saying well we're screening you and we detect you know this particular problem and then the employer saying well you know I'd just rather not deal with that it's a version of the insurance difficulty. Let's talk about costs. Over diagnosis over screening this has got to have a big cuz I mean one of the things that is the underpinning of the discussions at the Supreme Court about the Affordable Care Act you know really have to do with cost in our cost in America our health care costs are runaway. Nobody would disagree with that. How much does it cost to add the kinds of screenings that right now seem to be typical.

Well I don't have a good number for you Kelly but but there's no doubt it's big and probably the best evidence that it's big is because it's such a good market and that's why that's why so many why there is such a strong financial incentive to get into this area why it's good for hospitals to offer free screening why it's good for drug companies to change definitions of disease. And what we consider normal or abnormal. It's because it helps involve more people and involving more people means there's more money to be made and thus there are more costs to be had and the costs are probably less about the tests themselves than all the downstream events that happen following an abnormal test the more invasive tests that follow or the treatments that follow that. But I want to emphasize this issue from my standpoint is not about money. Even if you had all the money in the world. I think we all need to begin to look a little bit harder about this question of Is it a

good thing for the health care system to be looking hard for things to be wrong with us. I think the tradeoffs there are important enough that even if you had all the money in the world you'd want to consider this question To what extent do I want to be examined carefully carefully carefully looking for things to be wrong. The reality is it's a recipe for almost all of us to be told that we're sick somehow. Art Caplan the U.S. Unfortunately for all of our many toys and sophisticated tests of of all sorts is behind often behind other countries in thinking of alternative ways of handling certain certain issues and I wonder if there. Other countries other places in the world where they've figured this out and gotten the balance right or right to her. Yeah I'm going to give you a concrete example of that. I think we love testing prenatally we love testing. All we

can to see of that Pete is doing. But in the UK under their health system every woman who's had a baby gets a WILL BE visit from a nurse within the first month or two of their child being born and they go over breastfeeding and how to deal with a child in colic and other things that often times particularly first time moms aren't necessarily sure how to manage having a will baby visit. To me is worth a lot more than all the screening you can mount up and stack in the end it really contributes far more to health. So sometimes what you need to do is make sure that you're getting if you will. A good sensible eye into the situation. Some kind of coaching or training to see what you can do to improve health behavior. Just testing and testing alone as I was trying to say earlier. If you don't have time to talk about it explain it. Come to some kind of agreement about how you're going to manage it. That's not a good use of money just throwing testing information around. And then in other instances

which you want to do is make sure that you get better behavior. I give a little cost of testing bill ability of testing just to see that will be Visit program come here. So what's going to happen in the next few years our doctor Welch's voice a cry in the wilderness so to speak are our people starting to to hear this. And there's more and more evidence I know documented evidence that a lot of the screening is is not doing what folks thought but isn't some going to change. I'm thinking about this in terms of do I want to end this or. Discussion with a complete depression of Dr Wells. But I think the odds are a little bit stacked against him in that the legal climate as we've said does encourage defensive testing. There is a big industry building fast particularly in the genetic spear to do these kind of early testing at risk testing it's growing every day. The

neurosciences with brain scans are quickly going to follow behind this. I don't see any big effort to add more time to doctor patient conversation to give some relief to primary care people to try and explain testing better train them or for that matter to engage the pharmacist or other health care personnel and also being able to counsel about this testing. I think the message that he is bringing has to be heeded. It is crucial to understand the downside or sometimes the manse overuse but we are society like gizmos. We love those tests. We tend to be fascinated by the idea that somehow a magic number will make us to be mortal. I wouldn't want to bet on that. Deduction the diagnostic screening test. Dr. Welch with moments to go. Can you share if this all of this has changed the art of medicine.

Oh I think it has. I think in a way it's distracted us from listening to our patients actually hearing what's going on with their life as more and more effort is sort of going into sort of routine testing. And so I think it's had a very definite effect on medicine. You know it's really change you know as I said when I was in medical school our focus was on sick patients and now we still care for sick patients but increasingly we're spending more and more time looking for things to be wrong in the well. I agree with Dr. Caplan this is a formidable challenge. There's a lot of forces lined up sort of supporting more testing and so forth. I do think though the conversation has changed dramatically in the last 10 years and more and more of the public understands the two sides of the issue. They understand that more medical care isn't always better and that more diagnosis isn't always better and I think there's greater appreciation that we

need to find a better balance. Thank you both so much for a thought provoking conversation. We've been talking havoc. Oh you're welcome. We've been talking about over treatment and over diagnosis. I've been speaking with Dr. H. Gilbert Welch and Art Caplan. Dr. Welch is a professor of medicine at the Dartmouth Institute and author of Overdiagnosed Making People Sick in the pursuit of health. Art Caplan is a bioethicist who will soon be head of Bioethics at the language school of medicine at NYU. For complete Supreme Court health care coverage you can visit WGBH news dot org. Today's show was engineered by Antonio only art produced by Chelsea Mertz will Rose live and Abby was a go. This is the Calla Crossley Show a production of WGBH Boston Public Radio.