If you knew you had one year to live, would you have medical tests you didn't need?
Turns out a surprising number of patients with late-stage cancer get useless screening tests for new cancers that couldn't possibly kill them.
A new study of Medicare patients with cancers so advanced they had limited life expectancies and little hope of cure reveals "a culture of screening on autopilot," said lead author Dr. Camelia Sima of Memorial Sloan-Kettering Cancer Center in New York.
The study found advanced cancer patients got far fewer tests than healthy people. Still, 9 percent of the women received screening mammograms and 6 percent got Pap tests for cervical cancer, 15 percent of the men were checked for prostate cancer and 2 percent of the patients had tests for colon cancer.
"Doing screening tests on patients whose life expectancy is extremely limited because of cancer is just not a cost-effective thing to do," said Dr. Allen Lichter, CEO of the American Society of Clinical Oncology, who wasn't involved in the research. "The authors have done a wonderful service by pointing this out."
The study, appearing in Wednesday's Journal of the American Medical Association and funded by the National Cancer Institute, is the first to look at the issue of overtesting in late-stage cancer. It raises new questions about overdiagnosis and overtreatment in the U.S. health care system.
The benefits of early detection of cancer are clear in some patients. But it's still uncertain, for example, how early to start regular mammograms in women. And men older than 75 shouldn't get a PSA blood test for prostate cancer at all, according to government guidelines, but about one-third do.
What's the harm? Too many tests can raise anxiety in patients and lead to unneeded follow-up tests and treatments such as radiation and surgery that can have serious complications.
"People need to understand better that many screening tests are double-edged swords" that should be used selectively, not indiscriminately, said Dr. Howard Brody of the University of Texas Medical Branch in Galveston, who was not involved in the new study.
But doctors don't want to steal hope from late-stage cancer patients and are reluctant to talk about limited life expectancy, Lichter said. Doctors treating such patients need to have "frank and open discussions of end-of-life planning," he said. Without such discussions, it's awkward to explain to a patient why she doesn't need to have her annual mammogram anymore.
"The woman says, 'Why?' and you end up having to say, 'You're not going to live long enough,'" Lichter said.
The researchers crunched numbers on nearly 88,000 Medicare patients with advanced cancer. Most of the patients (61 percent) had lung cancer. Others had cancers of the colon, pancreas, esophagus and breast.
All were 65 or older and had been diagnosed between 1998 and 2005. On average, they lived less than two years following diagnosis.
The researchers excluded screening tests during the first two months after a cancer diagnosis to make sure they weren't mislabeling tests that helped in the diagnosis.
Medicare pays roughly $130 for a mammogram, $25 for a PSA test, $30 for a Pap test and from $300 to $700 for a colonoscopy.
Fixing the problem wouldn't mean huge savings for Medicare, Sima said, because few patients are involved. And while it might make scientific sense, it would be politically unworkable for Medicare to stop paying for cancer screening for patients with less than two years' life expectancy, she and others said.
Brody said the early screening message has been so successful that people think they're being deprived of "something of great value" when overtesting is discussed.
And politicians have seized on the issue with talk of "government getting between you and your doctor," Brody said. Sensible health policies will depend on voters to "smarten up to the point where this demagoguery no longer works," he said.