Coronary Calcium Scans Can Raise Cancer Risks

Interesting articles from the Annals of Internal Medicine and reported in HealthDay courtesy of Yahoo.

In summary, there is risk of radiation with using CT scan to determine if there are blockages in the coronary arteries. Note that from the article, "having such a screening test every five years would cause 42 additional cases of cancer among 100,000 men and 62 additional cases among 100,000 women."

Yet as one of the doctor notes it isn't proven that this screening test saves lives or is better at predicting who is at risk for heart disease than the usual measures of cholesterol, blood pressure, smoking status, age, and gender. (You can calculate your risk of having a heart attack or dying of a heart attack using the calculator provided by the National Cholesterol Education Program).

Interestingly, when hormone replacement therapy (HRT) for women in menopause was found to increase risk of cancer by 8 in 10,000 or 80 in 100,000, which is a little more than the increased cancer risk by this CT scanning, doctors and women essentially stopped using HRT. It was probably easier to do because there were alternatives to HRT.

Currently the US Preventive Services Task Force doesn't recommend it. The American Heart Association only suggests it for certain cases. Yet, unfortunately the state of Texas requires that the procedure be covered for all despite no evidence it works. Perhaps that is why a city in Texas was singled out as spending the most for medical care in a recent piece by physician author Atul Gawande in the New Yorker.

There are alternatives to using a CT scan to check the arteries to determine risk factor for heart disease. Until proven, it is best to stay away. Also, more importantly, quit smoking, stay active, maintain a healthy weight, control your blood pressure (ideally less than 120/80, but see your doctor if greater than 140/90), and control your cholesterol.

The entire article is here.


Coronary Calcium Scans Can Raise Cancer Risks
HealthDay Reporter by Ed Edelson

Mon Jul 13, 11:48 pm ETMONDAY, July 13 (HealthDay News) -- When weighing whether a coronary calcium scan is worth the risk, a new study suggests that arriving at an answer won't be clear-cut or easy.

A team of researchers from the U.S. National Cancer Institute and Columbia University found that the average range of radiation exposure from having such a screening test every five years would cause 42 additional cases of cancer among 100,000 men and 62 additional cases among 100,000 women. However, given the wide range of radiation doses seen in the study, the increase could be as low as 14 cases and as high as 200 cases among 100,000 men, and as low as 21 cases or as high as 300 cases among 100,000 women.

This is an issue of growing importance on the American medical scene, said Dr. Andrew J. Einstein, director of cardiac computed tomography research at Columbia University, and a member of a team that reports its findings in the July 13 issue of the Archives of Internal Medicine.

"There has been great interest recently in computed tomography, owing to the fact that the number of CAT scans has grown tremendously in the United States," Einstein said. "The National Council on Radiation Protection & Measurement estimates that 70 million are done per year."

The study in which Epstein took part looked at a form of computed tomography that scans for calcium deposits in heart arteries. CAC scanning, as it is called, is one of the lesser-done forms of computed tomography, but a private organization, Screening for Heart Attack, Prevention and Education, has proposed that it be done annually on 50 million Americans, and a new Texas law mandates health insurance coverage of the procedure.

The new study looked at what a dose of radiation in a single CAC scan would be, and found an enormous variation. There is no single protocol -- set of rules -- for such a scan, which can be done on a variety of equipment, Einstein said. "This was first proposed in 1990, and CT scanner technology has changed, so it is not clear what the protocol might be," he noted.
The study found roughly a 14-fold difference in radiation dosage among the various CAC scan protocols. Eliminate two or three "outlying" readings, and the difference is still threefold, Einstein said.

But those estimates are suspect, said Dr. Thomas G. Gerber, an associate professor of medicine and radiology at the Mayo Clinic, and co-author of an accompanying editorial, because it is based on extrapolation of the damage done to people exposed to high doses of atomic bomb radiation at Hiroshima and Nagasaki.

"At the very low doses used in medical imaging, there is a huge controversy about whether there is an increased risk of anything," Gerber said. "Estimates of increased risk are based on a linear no-threshold hypothesis. There is even a theory that chronic exposure to low doses of radiation might be beneficial."

There is equal cloudiness on the benefit side of the equation, said Gerber. "I am not a strong proponent of screening," he added.

"The risk of cardiac events increases if calcium is present in the arteries," Gerber said. "But you can't pick up blockages before they are 70 percent or more. There is some debate about whether the risk predicted by coronary calcium screening is incremental [adds to] the risk predicted by conventional risk factors. It stands to reason that it might be, but that is not proven."
The U.S. Preventive Services Task Force recommends against using CT scans in screening programs, and the American Heart Association says they should be used for "selected individuals" at intermediate risk.

So what do physicians do about CAC scanning in the real world?

"I like using it for patients at intermediate risk of coronary disease, when I do not know how aggressive therapy should be," Einstein said. "For such patients, it is a fantastic test."

"In my practice I use it for patients with no symptoms but an unfavorable risk factor profile," Gerber said. "If there are risk factors but they are adamant about not changing their lifestyle or taking coronary medication, I think it sometimes helps patients realize their coronary atherosclerosis [hardening of the arteries] has begun."

A definitive study of the risk-benefit ratio of CAC scanning is unlikely, Einstein said. The people in question are not at high risk of heart disease, and "the rarer an event is, the larger the sample size that is needed," he said. "A randomized controlled trial would require hundreds of thousands or millions of patients, with adequate follow-up."

More information
For more on coronary calcium scans, go to the U.S. National Heart, Lung, and Blood Institute.
Sphere: Related Content

1 Out of 3 Breast Cancers Overtreated or Screening Finds 2 Out of 3 Deadly Breast Cancers?

Associated Press discussed a recent article in the BMJ which found that 1 out of 3 breast cancers were overtreated based on review of breast cancer screening programs in Britian, Canada, Austrailia, Norway, and Sweden. Specifically that screening tests are unable to tell which breast cancers are potentially more deadly and which ones are less so.

The study's results are troubling not because of the screening tests inability to differentiate between aggressive cancers compared to more slow growing. The problem with this report is what the public hears and does.

Specifically, women might not get screened.

Note that the countries listed all have better healthcare outcomes than the United States. There levels of screening are far better than in the United States. We already are the worst among industrialized countries on doing basic things like vaccinations, cholesterol, blood pressure control, and screening tests like mammograms, colon tests, and prostate exams. As a country, there is probably a lot more we must do before we have the issue of "overtreatment".

If both men and women hear that screening causes cancers to be overtreated that they won't get screened. There will be too many preventable deaths and major costs to families which are bankrupting.

What the report could have said was screening in fact detects potentially fatal cancers 2 out of 3 times.

From the article -

Study: 1 in 3 breast cancer patients overtreated
By MARIA CHENG – 21 hours ago
LONDON (AP) — One in three breast cancer patients identified in public screening programs may be treated unnecessarily, a new study says. Karsten Jorgensen and Peter Gotzsche of the Nordic Cochrane Centre in Copenhagen analyzed breast cancer trends at least seven years before and after government-run screening programs for breast cancer started in parts of Australia, Britain, Canada, Norway and Sweden.
The research was published Friday in the BMJ, formerly known as the British Medical Journal. Jorgensen and Gotzsche did not cite any funding for their study.
Once screening programs began, more cases of breast cancer were inevitably picked up, the study showed. If a screening program is working, there should also be a drop in the number of advanced cancer cases detected in older women, since their cancers should theoretically have been caught earlier when they were screened.
However, Jorgensen and Gotzsche found the national breast cancer screening systems, which usually test women aged between 50 and 69, simply reported thousands more cases than previously identified.
Overall, Jorgensen and Gotzsche found that one third of the women identified as having breast cancer didn't actually need to be treated.
Some cancers never cause symptoms or death, and can grow too slowly to ever affect patients. As it is impossible to distinguish between those and deadly cancers, any identified cancer is treated. But the treatments can have harmful side-effects and be psychologically scarring.
"This information needs to get to women so they can make an informed choice," Jorgensen said. "There is a significant harm in making women cancer patients without good reason."
Jorgensen said that for years, women were urged to undergo breast cancer screening without them being informed of the risks involved, such as having to endure unnecessary treatment if a cancer was identified, even if it might never threaten their health.
Doctors and patients have long debated the merits of prostate cancer screening out of similar concerns that it overdiagnoses patients. A study in the Netherlands found that as many as two out of every five men whose prostate cancer was caught through a screening test had tumors too slow-growing to ever be a threat.
"Mammography is one of medicine's 'close calls,' ... where different people in the same situation might reasonably make different choices," wrote H. Gilbert Welch of VA Outcomes Group and the Dartmouth Institute for Health Policy and Research, in an accompanying editorial in the BMJ. "Mammography undoubtedly helps some women but hurts others."
Experts said overtreatment occurs wherever there is widespread cancer screening, including the U.S.
Britain's national health system recently ditched its pamphlet inviting women to get screened for breast cancer, after critics complained it did not explain the overtreatment problem.
Laura Bell of Cancer Research UK said Britain's breast cancer screening program was partly responsible for the country's reduced breast cancer cases.
"We still urge women to go for screening when invited," she said, though she acknowledged it was crucial for women to be informed of the potential benefits and harms of screening.

On the Net:
http://www.bmj.com
Copyright © 2009 The Associated Press. All rights reserved. Sphere: Related Content

Healthcare Reform Does NOT Require Rationing

The Washington Post printed a piece titled, "In Retooled Health-Care System, Who Will Say No?". Obviously a very tricky question to answer. The healthcare system without significant changes will generate costs out of control.

The federal government is loathe to do what England has done by indicating what is and isn't covered.

Patients certainly don't know what tests, imaging studies, or medications are needed to stay healthy or get better. Often they are fooled by slick advertising as well as the false belief that more is better (perpetuated by medical dramas like ER and House).

Insurance companies have tried, but given their past track record it is doubtful they can lead the change.

So who will say no? It's the doctors. Frankly it isn't as much as saying no as it is about refocusing what patients really want. What they really want is just the tests, imaging studies, and medications that they need to get better and well. They really don't want everything under the sun.

Research shows that we do too many tests, procedures, and interventions and the outcomes are actually worse! There is plenty of opportunity to still deliver high quality care without falling into the trap, which we are all victim to that newer is better. Don't buy this lie!

The problem is that the reimbursement system rewards doctors to do more. Until that changes, nothing will change. If reimbursement does change, then will doctors have the ability to counsel their patients on what the right care is when in the past, it was wrongly believed that more is better? Sphere: Related Content

Misleading Advice - Sacramento Magzine article - 8 Medical Tests that MIGHT Save Your Life

Forbes ran a similar article about 8 medical tests that could save your life earlier this year. It was accurate, thoughtful, and correctly identified the "test madness" that is pervasive in our country. In a completely different perspective, Sacramento magazine had an article in the July issue titled as 8 medical tests that can save your life.

Unfortunately, that isn't true. The article perpetuates the lie that more testing is better.

The article would have been better titled as tests that MIGHT save your life.

The heart scan, vascular screenings, even the annual skin cancer check, not one has been proven to save lives. Theoretically they seem to make sense, but there is no evidence.

And that's the problem.

Our healthcare system spends a lot on high-tech gee-whiz imaging studies and the public is infatuated with these tests with television shows, like House, which highlight their use. Yet a recent article in the New Yorker by physician writer Atul Gawande, found while we in the United States order more tests we aren't healthier for it.

The problem with increasing technology and actually worse health outcomes has been illustrated in Shannon Brownlee's book Overtreated. Doctors assumed that metastatic breast cancer patients would need bone marrow transplants to save their lives, because of the phenomenal success of curing blood cancers like leukemias and lymphomas with the same treatment.

Insurance companies refused because there was NO proof to that theory, even though it sounded nice. Ultimately, insurance companies buckled due to public pressure and outcry when breast cancer patients felt that it was denial of medical care. Was it a win for patient advocacy?

Here's the sad irony. Despite many desperate women undergoing brutal chemotherapy for bone marrow transplant, the research results finally showed that standard chemotherapy was better. Bone marrow transplant killed women, who falsely believed that it was superior. They died unnecessarily and needlessly because there was no proof.

Conclusion? This Sacramento magazine article should have been titled as 8 Medical Tests that "MIGHT" Save Your Life rather than "CAN". Save your money on these questionable exams. There is a reason why insurance companies won't pay for them. They aren't proven to save lives.
In the end, that is what really matters. Sphere: Related Content

Infant's Tylenol and Children's Tylenol Not the Same

My appearance at the local ABC affiliate in Sacramento today. Sharon Ito summarized the variety of topics beautifully.

I will be at the Sacramento - Arden-Dimick library on Monday July 20th from 630 pm to discuss how to talk to your doctor. It has been a topic well received when I have spoken at various places including Intel, Sun City Lincoln, and Borders.

SACRAMENTO, CA - On Monday's Live_Online, Kaiser family physician Davis Liu, talked about the proper use of medication and answered your medical questions.
In the wake of the FDA's recommendation about lowering the over-the-counter dosage of Tylenol, Liu said parents should know that infant and children Tylenol products contain different dosages.

Liu said the infant formula is more concentrated than the children's variety, so parents should stick with the age and dosage requirements for each Tylenol product.

Liu also said if patients have had a prior drug or alcohol addiction, they need to tell their doctor before they receive any new medications, so their sober status isn't put in jeopardy.

Liu also said patients need to tell their doctors if a medication or a medical test is too costly. Doctors might be able to substitute a cheaper drug or postpone a test, without putting the patient's health at risk.

Liu will be presenting a workshop on How to Talk to Your Doctor on Monday, July 20, at 6:30 p.m. at the Arden-Dimick Library in Sacramento.

You can see the entire interview with News10's Sharon Ito in the Live Online Archive.
You can always send an e-mail to: LiveOnline@news10.net

News10/KXTV Copyright 2009 / All Rights Reserved


Here's the entire interview.


Sphere: Related Content

Patients Don't Want To (and Can't) Reform Healthcare System

Don't misinterpret the heading of this entry. It's not that patients don't want healthcare reform. It's that patients don't want to be the responsibility of reforming the healthcare system.

And who could blame them.

Although it appears that the federal government is working to reform the healthcare system, one will periodically hear experts talk about consumer driven healthcare. That is, give patients more financial responsibility for their health through higher deductibles and copays and health savings accounts. Seeing this increased financial burden, they will consequently make better choices about their health, shop around for the best care, and make more rational decisions about when to seek medical care much the same way they do for other services and goods.

Please.

Note how the the person in a story in the Economist managed to spend a lot of money for a strained muscle.

I would note that giving the public more responsibility for reforming a benefit program occurred decades ago with retirement planning. Employers stressed by the increasing obligations from pension plans opted many years ago to move from defined benefit plans to defined contribution plans. Pension plan now becomes a 401k plan. The burden of having enough assets to comfortably retire moved from employer to employee. Theory was individuals now would take charge and do better.

Right.

We now know that this was a disaster for nearly everyone, except for the financial services industry it created. Individuals didn't save money or invest in the right financial products. Many were in cash, which generally doesn't keep up with inflation. As a result, employers are becoming more involved requiring people to opt out of a 401k rather than opting in, choosing a target date mutual fund account as a default rather than cash, and spending resources on educating their workers more about financial planning.

So the problem with healthcare? Patients don't have the expertise and don't wish to grasp the nuances of medical diagnosis and treatment. They falsely believe that the answers to their problems and ailments come from the high-tech MRIs and CT scans, blood work, and other tools at our disposal as doctors. It could be due to television shows like ER or House or doctors doing extensive work-ups with little thought on costs or relevance. Nevertheless, with increasing co-pays, patients feel that to solve their problem, forgo the doctor visit and simply order a test.

Unfortunately, these tests are merely tools and can help provide doctors clues into what is happening, but don't provide the universal truth. In other cases, we don't need the test because it is quite clear what the problem is. However, Dr. Scott Haig notes in a recent Time article that it is practically impossible to convince patients otherwise. They want the tests even though it is obvious what is happening.

I see it in my office plenty of times.

• How do you know what the skin rash is without doing a biopsy? (Answer - do you know what acne looks like? You don't need biopsy that do you? The reason we go to medical school and residency programs for a minimum of seven years isn't to figure out what tests to order, but how to correctly diagnosis and treat illness and get you better).
  

• I'm having chest pain and I want at CT scan (which is the 64 slicer CT scan which rules out an pulmonary embolus - blood clot in the lungs, a dissecting aortic aneurysm, or a heart attack - acute coronary syndrome) as well as the medication PLAVIX to thin the blood. (Answer - After spending quite a bit of time asking questions about the symptoms and what made it better or worse, it was clear the symptoms were due to irritation of the esophagous due to increase alcohol usage. Had those tests been ordered, it would have cost the patient more as he would need to pay for the procedures, discovered that the tests were all normal, and at the end NOT solve anything. CT scans don't diagnose esophageal reflux. So this patient would have returned for a second office visit and say I'm still hurting and undoubtedly demand more tests. Is he better off healthwise or financially?).
  

• I'm having a migraine headache and I want an MRI. How do you know it's a migraine? (Answer - From your classic history of your mother having a migraine, when she was diagnosed MRI technology didn't exist and doctors got it right, your symptoms of a throbbing unilateral headache which worsens with physical activity, at times can cause nausea, vomiting, sensitivity to sounds and light, and typically better with quiet dark rooms, and a total episode time of 24 to 48 hours. Incidentially, when the MRI of the head comes back as normal, does that mean you don't have a migraine? If you still have pain does that mean the MRI was wrong? Did the MRI add any value to your visit?)

Why do patients behave this way? The reimbursement structure of our healthcare system provided incentives to do more. Doctors are paid piecemeal. Do a procedure, get paid. We get paid for quantity and volume not quality. As a result, patients fall into a trap thinking that getting more is better care when in fact research shows Americans get more spent on healthcare per capita than any industrialized country in the world and yet we rank dead last on health outcomes.

Finding a smart doctor who knows how to diagnose you by asking the right questions and thinking is truly a blessing. If you find one that sits down, talks to you, and tries hard to understand your symptoms so it is clear in her mind what your problem is, never give her up. Anyone can order tests and xrays. Only a few can figure out when it is needed and when it is not.

I don't blame doctors who occassionally cave-in to patient demands. I do worry about those who do most of the time to placate a patient. Patients see us to get better and unfortunately they wrongly believe that requires extensive testing. If we continue to perpetuate the lie and if consumer driven healthcare advocates have their way, we'll see more healthcare costs and worse outcomes, not better.

What do patients really want? They want doctors to listen and order tests, imaging studies, and medications that are necessary to get them better or keep them well. They want healthcare to be affordable and accessible.

What they don't want is the responsibility of reforming the system. They don't have the expertise to do so.

I don't blame them. Sphere: Related Content

Save Money on Medical Costs - 10 Tips from Money Magazine

The July issue of Money magazine article "Beat the rising cost of health care" has a quote from yours truly!

• Finally, ask about alternatives, says Davis Liu, a family doctor and the author of "Stay Healthy, Live Longer, Spend Wisely." For example, your doctor may suggest an MRI to figure out why your back is hurting. But if you push back a bit, she may also tell you that you can first try back exercises for a few weeks and see if the pain goes away on its own. It very often does.

Overall great tips. Without serious healthcare reform, the brutal reality is this. We are already rationing healthcare in this country. It's not based on your age, health, or research. It's based on your ability to pay. Sphere: Related Content