45 medical tests or treatments to avoid

Our medical care system has become a danger, an expensive, wasteful danger at that. So what else is new? You might ask. Now doctors themselves are recognizing the problem and going public with warnings, specifying tests and treatments to avoid under certain circumstances.  The primary care physicians led the way last year when they named the top ten “don’ts” in their field. Now nine specialty organizations have weighed in with their versions.  A momentous move, given the fact that these specialists are putting aside their own economic self-interest and warning their peers as well as the general public about the harm of overtesting and overtreatment.

Altogether 45 tests or treatments made the new list—five for each specialty. Yes, it’s about saving money; an estimated $660 billion is spent annually on unnecessary healthcare in U.S. And no, this is not about rationing; it’s about improving the quality of medical care and using it wisely.

The theme of this project, called Choosing Wisely, is this: Virtually all medical interventions entail some risks both large and small. An example of the former is the huge radiation dose delivered by CT scans; an example of the latter is the small chance of a puncture-related infection from a screening colonoscopy. And some tests that are risk-free can cause false-alarms that lead to more tests that are not. If you have nothing to gain from a test, why take even a small risk?

Here’s a “nothing to gain” example from the oncologists’ list: “Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer or early breast cancer at low risk for metastasis.” Some reasons: “A lack of evidence to show these tests improve detection of metastatic disease or survival. Unnecessary imaging can lead to harm through unnecessary invasive procedures, overtreatment, unnecessary radiation exposure, and misdiagnosis.”

There’s also a recurring theme within the lists, namely, avoid imaging people without symptoms and people at low risk for the relevant disease. People in one or both of these categories run the risks but have nothing to gain in terms of improved outcomes. Examples: pre-operative chest x-rays, cardiac imaging stress testing for people without symptoms of heart disease.

Some lists warn against imaging even for people with symptoms, such as brain imaging for fainting or for uncomplicated headaches, because there’s no proof it improves outcomes. The cardiologists’ top five is all about inappropriate use of imaging with radionuclide and CT scans.

The strongest warning about reducing radiation exposure came from the American Society of Nuclear Cardiologists:  “Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.” The word ‘methods’ also refers to calibrating the machinery to produce the best image with the lowest dose.

Sometimes a standard practice is just a waste of the patient’s time and money like this example from the allergists: “Don’t routinely do diagnostic testing in patients with chronic urticaria [hives]. Routine extensive testing is neither cost effective nor associated with improved clinical outcomes.”

Few treatments are addressed in this project, although one tops the gastroenterologists’ list.  It refers to the drugs like Prilosec and Nexium, which are widely prescribed for heartburn, gastroesophageal reflux disease, and gastric ulcers. The gastroenterologists’ advice: Use the lowest effective dose. (Click here for extensive information on this topic from Consumer Reports, which participates in Choosing Wisely.) The gastroenterologists also want their peers to restrain themselves on the repeat colonoscopies even for people who have had small polyps removed.

Another treatment example comes from the kidney specialists who are concerned about the overuse of a class of anti-anemia drugs.  “Don’t administer erythropoiesis-stimulating agents [Procrit, Aranesp, Epogen, and Eprex] to chronic kidney disease patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.” The kidney specialists could have taken a stronger stance with this example, given the fact that these drugs’ effectiveness is in doubt and they have killed an estimated half million people.  Click here for a Whistleblower’s Story.

Inform yourself

We consumers have a role in driving the market for unnecessary testing. Here’s the doctors’ side of the story: 30% of them admit that they order tests they know won’t help their patients but order them anyway because patients come in asking for them.  On the other hand, 80% of all medical care expenditures is driven by physicians.

Read more about Choosing Wisely, an initiative a foundation established by the American Board of Internal Medicine.  Click here for the names of specialty organizations and their respective lists.

Maryann Napoli, Center for Medical Consumers©
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The primary care physicians’ list of 2011.
Heart screening tests
CT Scans: Lots of radation, little research

CT Scans—Lots of Radiation, Little Research

“The increase in CT [scan] use and in the CT-derived radiation dose in the population is occurring just as our understanding of the carcinogenic potential of low doses of x-ray radiation has improved substantially, particularly for children.”

The low-dose in this quote is relative to the amount of radiation absorbed by atom-bomb survivors—long the only yardstick available to radiation-safety researchers. It appeared in a 2007 report in The New England Journal of Medicine which states that, contrary to conventional medical wisdom, the doses received by a CT scan carry a small but definitive risk of cancer. The lead author is David J. Brenner, PhD, Center for Radiological Research, Columbia University Medical Center, New York.

The radiation dose from a CT scan is far larger than that of a conventional x-ray because it typically involves 64 “slices” of radiation exposure, compared to one or two views of a standard x-ray. The American Heart Association, not known for warning the public about the negative aspects of medical care, acknowledged recently that the amount of radiation from a heart scan is equivalent to 600 chest x-rays.

Each scan creates an additional lifetime risk of cancer that is somewhere between 1 in 200 and 1 in 5,000, according to Dr. Brenner. Unfortunately, consumers who try to get information about radiation exposure from their doctors are unlikely to get an accurate answer. In a 2004 survey of radiologists and emergency room physicians, 75% of the entire group significantly underestimated the radiation dose from a CT scan. Worse, 53% of radiologists and 91% of the E.R. doctors did not believe that CT scans increased the lifetime risk of cancer.

Massive Increase in Scans
The large amount of radiation that concerns researchers like Dr. Brenner is due to the technology itself, as well as the alarming increase in usage. An estimated 62 million CT scans are now done annually in the U.S., up from 3 million in 1980. Lately, heart scans have become a source of alarm. The installation of cardiac scanning equipment has tripled in the U.S. in the past two years.

A recent international study in the Journal of the American Medical Association is the first to look at the radiation dose from a heart scan, aka cardiac CT angiography, as it is performed in the real world. The 50 study sites included in this research project were 21 university hospitals and 29 community hospitals. The research team led by Jorg Hausleiter, MD, found doses varied widely according to the equipment and the study site. Worst of all, the available strategies for reducing doses were not being used.

One of the obvious recommendations to emerge from this study is: “Low voltage scanning should be considered, especially for patients who are non-obese and at higher risk of radiation-associated cancer, such as children and young women.”

No one would deny that CT scans are an excellent diagnostic tool that may well have saved many lives. The problem is the complete lack of information. As often happens in the U.S., enthusiastic reception of a new technology—by doctors and consumers alike—precedes the science that would identify those people for whom the benefits outweighs the risks.

In many cases, the purportedly new, improved scan has never been proven in a large clinical trial to be better than the older, less expensive tests. Our profit-driven medical care “system” encourages the premature introduction and widespread acceptance of a new, costlier procedure. Add to the mix, entrepreneurial physicians who co-own the scanning equipment and have a financial incentive to overuse it.

Screening Uses Questioned
The first place to start questioning CT scans, according to Dr. Brenner, is their use for symptomless people. Healthy people are the ones most likely to harmed because they would incur the risks of a high radiation dose and overdiagnosis to receive an uncertain benefit. None of the following screening scans has been proven to be life-saving.

CT colonography, or “virtual colonoscopy,” is often regarded as a less-invasive alternative to the standard colonoscopy. It’s unlikely that many people who choose this method of colon cancer screening are informed of the high radiation dose or its penchant for finding abnormalities in nearby organs that lead to other investigations, some quite risky, that often prove to be benign (i.e., overdiagnosis).

CT lung screening for smokers and former smokers: This relatively new technology has become popular, despite the lung scan’s ability to find non-lethal cancers that are usually treated. A large ongoing government-sponsored clinical trial that has randomly assigned smokers and former smokers to a spiral CT lung scan or no scan will provide answers to two questions for this select group of individuals: Will regular scanning reduce their death rate? Will it cause more harm than good?   Added 2011: Lung screening scans for heavy smokers reduce lung cancer deaths.

CT whole-body screening: This is a truly awful idea promoted by Oprah Winfrey and advertised directly to the public on the radio, the Internet, and in newspapers. A whole-body scan will extend all the radiation and overdiagnosis problems cited above to the rest of the body.

Heart Scans may make sense for people with symptoms like shortness of breath and chest pain. They are not useful, however, for predicting a heart attack or stroke in people without symptoms. Constrictions in the coronary arteries that show up in the heart scans of symptom-free people are not where a future heart attack will occur (though interventional cardiologists have been opening these constrictions for years on the now-discredited belief that they are saving the patient’s life). A heart attack occurs when bits of plaque break away from the arterial wall and blocks the blood flow to the heart. Scans cannot identify which blockages will rupture.

Maryann Napoli, Center for Medical Consumers© May 2009

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Radiation dose of cardiac CT scans

A CT scan of the coronary arteries is a good diagnostic tool, but it involves a large dose of radiation. To determine how much radiation is involved in cardiac CT scans (also known as computed tomography angiograms), researchers accessed data from 1,965 CT scans of the coronary arteries performed in 50 hospitals around the world. The average estimated dose was 12 mSv, which is the equivalent of 600 chest x-rays, although estimated exposures varied widely from place to place (5 mSv to 30 mSv).

The sixfold difference was caused by variations in CT scan protocols, hardware, and use of established strategies to minimize radiation exposure. One of them, called electrocardiographically controlled tube current modulation, or ECTCM, is well supported by evidence and is associated with a 25% reduction in radiation dose. Sequential scanning and low voltage scanning were mentioned as other effective options for limiting exposure. Only a minority of patients in this study, however, were scanned using either strategy.

Protecting patients from radiation is one of the basic principles of radiology, say the authors of this study, “Effective strategies to reduce radiation dose are available but some strategies are not frequently used.”

JAMA 2009;301:500– 7

For more information about radiation exposure from CT scans, click into our 2009 article, “CT scans—lots of radiation, little research.”

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