DRUG BUST Alan Cassels

Seek and ye shall find. We can find disease wherever we look; the question is do we need to be looking? One of the longest-running debates in health care circles involves the dichotomy of “prevention” versus “treatment.” Some people complain that our “health” system has nothing to do with health and basically exists to patch you up once you’re broken. It’s a system that, by design, ignores many of the factors that make us sick in the first place. Many people praise the need for prevention using very compelling arguments, stressing that the bucks need to go towards health promotion and disease prevention in order to save further billions on medical services down the road. This would avoid much needless suffering and engender a healthier, happier society at a fraction of the cost we currently incur.

There’s no doubt that, as a society, we need to do a better job of following the classic triumvirate of health promotion advice: Eat well. Exercise often. Don’t smoke. However, that which passes for prevention is often an exercise in consumerism to get us to part with even more of our dollars. All in the name of health, of course.

We’ve seen many examples of how “prevention” consumerism drives the use of pharmaceutical drugs prescribed to “prevent” all kinds of chronic disease, even when the evidence underlying those treatments really applies to only a small subset of “high risk” people who may benefit. The incessant drumbeat of preventative pharmacology persistently fails to remind us that many of those treatments provide infinitesimally small benefits for relatively healthy people at great costs with unknown risks.

The pharmaceutical industry is not alone in discovering that prevention sells. Others, particularly those that market organ screening with some of the highest tech tools on the planet, such as the CT (computed tomography) or PET (positron emission tomography) scanning machines, have discovered that screening for disease is a cash cow capable of providing a much more lucrative revenue stream than that yielded by simply providing treatments for the sick.

In fact, one way to sell “prevention” is to establish a market for screening for the deadliest diseases lurking in your body – seeking out markers of disease, such as heart disease or cancer, before the disease can get you.

This new generation of scanning devices wouldn’t look out of place in Dr. McCoy’s sickbay on the Starship Enterprise. These space-age devices generate three-dimensional images of your body’s insides and, in terms of diagnosing what is wrong with you, a CT or PET scan might be the best medicine for you. But, at the same time, because these machines are so good at detecting tumours and arterial plaque, entrepreneurs would naturally reason that we should grow that market by expanding the machines’ uses to more and more healthy people. In fact, why not send the whole population to get “screened,” under the guise that it would (like most arguments for prevention) ultimately save the health system money?

It’s not that simple. Population-wide screening of healthy people seems intuitively sound until you look a little closer and realize the costs and potential for harm are considerable, including, in this case, the massive doses of radiation that some of the tests themselves deliver.

What do we really know about the overall screening of the population using these devices? The answer is not much. And it provides no solace that even the screening paradigm about which we know the most – screening mammography for breast cancer – is no slam-dunk. Maryann Napoli, associate director of the Centre for Medical Consumers in Manhattan (www.medicalconsumers.org), has an in-depth consumer’s view of the controversies around mammography. In a recent interview, she shared some of the statistics with me: “For every 2,000 women who have mammography over the course of 10 years, one woman will have her life extended because she was saved from having or dying from breast cancer. Meanwhile, 10 more women will be diagnosed and treated for a cancer that they didn’t need to know about.”

The fact is the more mammography screening you do, the more things you’ll find. And the more stuff you find, the more you will be driven to determine if the lumps are lethal, beginning a cascade of biopsies, surgery, radiation, hormone therapy and so on. Any screening, if pursued too aggressively in well people, will deliver high rates of false positives – the equivalent of crying wolf. One of the surprising findings of mammography screening research, despite our profound belief in its usefulness, is that breast cancer death rates don’t vary, regardless of whether or not you religiously have mammograms or avoid them. The equation tilts in favour of older women being more rigorous about mammography, but then why do we still recommend screening so aggressively for younger women?

Cancers don’t just show up in the breast, and around the world, private entrepreneurs with scanning machines are promoting their high-tech search and destroy missions in hearts, lungs and other organs. In Canada, these scans seem to be currently limited to those who can plunk down the fee of several thousand dollars, unless you’re a CEO and you get the screen as a perk of “executive health” coverage. The promotion of these types of screenings tend to use a predictable technique designed to grab your attention: 1) the hook –sell the size of the problem. 2) the set-up – sell the wonders of the technology. 3) the pitch – and then close the deal by asking the customer to commit to some action.

The following two examples derive from a centre in a large, western Canadian city pitching its screens for lung cancer, heart disease, and other conditions.

Lung cancer screening

1. The hook: “The Lung Scan – The Best Defence is a Good Offence”

2. The setup: The most preventable of all cancers, lung cancer remains the leading cause of cancer death for both men and women.

3. The pitch: After quitting smoking, early detection may be your best defence against lung cancer. Researchers have recently demonstrated that routine CT screening reveals most lung cancers while they are potentially curable.

4. The close: The lung scan is very accurate in detecting small lung cancers before they become symptomatic or before they become visible on standard chest X-rays. Early detection of lung cancers can mean a longer life and, in many cases, a cure.

Heart Disease

1. The hook: “The Heart Scan – Know the Score”

2. The setup: Cardiovascular disease is the single greatest health problem in Canada and the rest of the developed world. Health Canada suggests 37 percent of Canadian men and 41 percent of women will eventually die of some form of cardiovascular disease.

3. The pitch: A heart scan is an “effective, non-invasive way to measure the amount of calcified plaque in blood vessels – your ‘cardiac calcium score.’ Once identified, at-risk patients can be treated for problems such as high blood pressure, cholesterol pathology and borderline diabetes, significantly improving their chances of survival.”

4. The close: “Starting at age 45 for men and 55 for women, individuals should consider a heart scan to determine their calcified plaque levels.”

So there you have it – all the reasons why you should be proactive. There is this disease – lung cancer or heart disease – that is a huge killer. You could be at risk. The technology could save you. And luckily for you, you can act now (and pay the thousands of dollars your scan will cost you). And the narrative flows to the point where you are willing to part with your money.

By now, you would probably like to ask me, “So what’s wrong with paying a few thousand dollars to find out if your body is harbouring any latent disease?” One way to answer this question is by asking yourself what matters to you.

Does it matter that a single CT scan could expose you to as much radiation as 300 chest x-rays, which, statistically, will cause cancer in a small number of patients thus exposed?

Does it matter to you if the World Health Organization, as well as almost every federal agency in Canada and the US and many radiology societies and associations around the world, gives the thumbs down to population screening of asymptomatic (healthy people) for coronary artery disease or lung cancer using CT scans? In other words, for a variety of reasons, the experts don’t recommend it.

Does it matter that the language used to sell many types of population screening is prone to many forms of bias? Three types of bias – lead-time, length time and overdiagnosis bias – collectively conspire to make the screening appear to improve your chances of survival when it actually doesn’t? (Check Wikipedia for a good explanation of the types of possible bias.)

Does it matter that many of us who are healthy are harbouring slow-growing tumours and other moles, lumps and bits inside our bodies that we don’t know about and which may never bother us, yet, if those things were to be discovered, the medical cascade of investigations, biopsies and surgeries (as well as complications arising from hospitalization and surgery) would tend to follow?

Let me conclude by saying that while we all hope that high tech, such as CT or PET screening, saves lives, it’s worth waiting for the evidence to back up that hope. In the meantime, it’s buyer beware; watch for the hook and beware of those ready to “close” the deal.

Alan Cassels is a pharmaceutical policy researcher at the University of Victoria and is the author of The ABCs of Disease Mongering. He is currently studying the marketing and regulation of private scanning in Canada. Have you been scanned? Do you have a story to tell? Contact him: cassels@uivic.ca