DC Medical Malpractice & Patient Safety Blog

Recent news reports suggest that getting only part of your colon scoped for precancerous lesions might be a good enough way to prevent colon cancer. But the real story is that whatever test you get, there is a wide variation in the quality of the colon examinations that doctors do, and out of hurry or poor training, some doctors miss a lot of lesions that should be taken out.

So if you want to have a safe, effective -- and potentially life-saving -- exam, you need to do some simple doctor screening to make sure the doctor is right for you.

The good news is it's not that hard. Research has found that two simple questions will bring out what you need to know to assure that all the trouble you're going through to get your colon examined will be worthwhile.

Before I lay out the questions, some quick anatomy to make this easy to understand:

The food we eat passes through the stomach and then through nearly thirty feet of small intestine before hitting the large intestine, or colon. The place where the small intestine joins the colon is called the ileocecal valve. It connects the ileum, the final part of the small intestine, to the cecum, the first part of the colon. The cecum is also where your appendix dangles off the end of the colon. In most people, the cecum and the appendix are in the right lower section of your abdomen. Intestinal contents travel from there vertically, in the ascending colon, up your right side toward the liver. The colon then turns 90 degrees to cross your belly from the right to the left. This section is called the transverse colon. Then the colon turns south in the descending colon, which runs down the left side of your abdomen. Finally it moves sideways one more time, in the sigmoid colon, which then reaches the rectum and the anus.

A colonoscopy uses a flexible telescope inserted through your anus to travel the entire length of the colon, to where it ends at the cecum. Most of the visual inspection by the doctor is done while the scope is being pulled back from the cecum to the exit at the anus.

A sigmoidoscopy, by contrast, only inspects the first foot or so of your colon. In some people, that's enough to find most precancerous growths. But in many, it's not. African-Americans, for example, have a higher rate of colon cancer in the further reaches of the colon beyond where the sigmoidoscope looks.

So the smart choice is to go with the full colonoscopy, even though the bowel preparation you have to undergo is more burdensome. That's the recommendation of the American Gastroenterological Association, the doctors' group that specializes in the intestines.

Now for the two questions to get the best chance of a good colon exam:

First, ask the doctor:

What is your detection rate of precancerous polyps?

(These are technically called adenomas). The rate should be at least 20 percent -- or 25 percent in men patients and 15 percent in women patients. A lower rate means the doctor is very likely missing precancerous lesions that are waiting to turn into cancer -- when the whole purpose of the colonoscopy is to find them and snip them off before they go bad.

The second question for the doctor:

What is the amount of time you typically take to inspect the entire length of the colon?

This answer should be at least six minutes. It takes that long to adequately inspect all the nooks and crannies.

Both these questions get at the same issue. You want to minimize the chance that a hurried examination will give you a clean bill of health by mistake.

How often does that happen? Frightfully often. In research published this year, the rate of colon cancers in people who had had a colonoscopy within the previous five years was ten times higher when the doctors who did the colonoscopy had a detection rate of ten percent or less, compared to doctors who had a detection rate of twenty percent or more.

Dr. Douglas Rex of Indiana University has written guidelines for his fellow gastrointestinal doctors about how to do an adequate colon exam. Dr. Rex is an advocate for careful comparison shopping by patients. In an article he wrote for fellow practitioners, he estimated that the doctors with the lowest detection rates are missing 75 to 90 percent of precancerous growths in the colon.

That's a huge number. But patients can do their part to make sure their colon cancers aren't missed by asking these simple questions before they undergo a colonoscopy.

A new survey in a medical journal says the overwhelming majority of doctors believe that defensive medicine is costing the nation billions of dollars a year and they need protection from malpractice lawsuits. But does it really add up?

There is no question that U.S. patients undergo many more tests and procedures than any other country, and that we don't show anything good for it in our health statistics compared to other countries with much more inexpensive care.

Doctors typically say their peers order unnecessary tests because the patient will sue them if they don't.

This has always struck me as a strange admission.

To get paid, doctors have to attest to the necessity of any test they order, so when they order these so-called defensive tests purely to protect themselves, they commit insurance fraud.

Of course, if there's any chance the test may help the patient by revealing a treatable problem, then the test was necessary and doesn't fall into the category of insurance fraud or defensive medicine. Yet many doctors seem to think it's only the extra threat of being sued for not ordering the test that pushes them over the line to ordering it.

The Wall Street Journal's Katherine Hobson wrote up the new survey on her health blog, which appeared in Archives of Internal Medicine, and drew some interesting comments from readers. One patient told his own story:

* Gerald wrote:

I have read comments here with interest. I have had a doctor tell me he was ordering a test on me more out of a fear of being sued, and that it “was probably not necessary.” I was shocked. I said, “Doc, you are telling me that if I have a brain tumor, and die, that is not a serious enough risk for me to have an MRI, UNLESS YOU COULD BE SUED FOR IT!” I had some severe headaches.

The doctor turned red with embarrassment, and perhaps shame. He apologized and said he did not realize what he was saying. He could only be sued if turned out to have a serious medical problem that could have been prevented by the test. He was admitting that my life was not enough motivation for the test, but if he could be sued for the lost of my life; then it was good motivation for the test.

The survey was not scientifically rigorous. As reported by the WSJ:

Researchers say that 91% of the 1,231 doctors who responded to their survey “reported believing that physicians order more tests and procedures than needed to protect themselves from malpractice suits.”

The "belief" by a survey respondent that some doctors order tests only to protect themselves is a far cry from admitting that one personally does this.

Another commenter, who identified himself on the WSJ blog as Rod Tucker Esq., wrote:

Every survey such as this one should require that the doctors give their names and specific examples of the tests they had done which they did not feel were necessary. Then their patients could ask why they were forced to undergo these often harmful and usually painful tests and why they were forced to pay for unnecessary acts by the doctor. The insurance company could also refuse to pay because the test was by definition unnecessary.

No person in business (doctors get paid for their work and are by definition in business) has the right to demand that they get to mess up and not be responsible to the innocent person they hurt. So instead of trying to give doctors a free pass how about we treat them like everyone else and ask the cost of a test and decide for ourselves if it is necessary, just like we do when we buy anything else.

Food allergies are frequently overdiagnosed because the two tests commonly used have less than a 50% accuracy rate, according to a new authoritative study. As a result, whereas three in ten adult Americans think they have one or another food allergy, the actual number is more on the order of one in twenty (5%) adults, and a little higher for children (8%).

The new study was sponsored by the National Institute of Allergy and Infectious Diseases, a branch of the NIH, and was reported in the Journal of the American Medical Association.

The skin prick test and the antibody test are the two main tests done for food allergies, but the only real way to know if someone has a true food allergy is to challenge their body by slipping them a small amount of the food and seeing if a rash or even bigger reaction results. That's a scary prospect for many patients, so the food challenge test is seldom done.

Another issue is that many people have a food intolerance -- like lactose intolerance due to a missing enzyme that breaks down sugar in milk -- but that is not the same as a food allergy, which happens when the person's immune system goes haywire in response to an allergen.

Read more in Gina Kolata's article in the New York Times and Katherine Hobson's WSJ blog article.

This study reinforces advice I give in my book, "The Life You Save." I don't think anyone should make major changes in their life based on one or two test results without making really sure that they have the condition. That can mean confirmatory testing, a second opinion, or just plain education so that you understand that no test result is 100%.

It's a wonderful, Star-Trek kind of fantasy: have a machine scan your body and turn up any abnormalities in minutes, with no pain, no inconvenience and little fuss. Some patients actually do it: with whole-body CT scans, or more targeted CT scans aimed at the colon (often called virtual colonoscopy -- President Obama had one) or the heart.

The problem is there's no good evidence yet that these scans are worth the expense or the huge dose of X-ray radiation that a patient receives: typically the equivalent of 400 chest X-rays with a single CT scan.

General Electric, a manufacturer of CT scan machines, is trying to get the Food and Drug Administration to give its official approval to the use of CT scans as a substitute for traditional colonoscopy. The application is still pending. At a hearing this week, FDA scientists are expected to complain about the pressure they felt from agency superiors to approve the application despite their concerns about the radiation risks. Read more on this in an article by Gardiner Harris in the New York Times.

Whole body screening with CT scans is something that few sober doctors recommend, unless they own one of the machines. The FDA has a good discussion here explaining why an apparent "abnormality" found with a whole-body scan can mean nothing, while the scan can also miss true disease.

The bottom line is that the images produced by these machines are good, but not good enough to start cutting out the abnormalities they seem to show. With colon, heart and other body parts, no surgeon will operate based solely on a CT scan. They want a closer look with a scope that shows the actual organ -- as a colonoscope does.

The other important fact to know about whole-body screening is that if you feel good and have no disease symptoms, the odds are very high that nothing is wrong with you. No screening device yet beats the human brain at picking up signals of abnormality (with a few exceptions like the silent disease of high blood pressure).

When a 44-year-old male friend dropped dead the other day from a massive heart attack -- no prior symptoms, no warning of any kind -- I wondered if modern medicine could have done anything to prevent the tragedy. The answer I learned is that low-tech still beats high-tech hands down in preventing America's No. 1 killer.

Low-tech means getting regular exercise, eating right and paying attention to cholesterol, blood pressure and the other risk factors for heart disease, and it also means moving fast to get to a medical facility with any symptoms whatsoever that might be signaling heart attack. Those are the proven ways to lengthen your life span and avoid early death.

But my friend didn't have any symptoms or risk factors. What could he have done? That's where high tech comes in, but the answers are not encouraging. The available treatments are expensive and not very effective for people without symptoms.

He could have had the gold-standard test for narrowed arteries in the heart: an angiogram. That's an X-ray movie of the arteries that involves putting a tube into the groin, threading it up to the surface of the heart, and squirting dye through the tube to outline the inside of the blood vessels as high-speed multiple X-rays are taken. I've watched these movies for some of my medical malpractice lawsuits, and they are eerily fascinating: the dye looks like smoke as it pushes out of the tube and mingles with the blood in the arteries, which suddenly light up as if a switch has been turned on, with the heart quivering all the while behind the arteries.

The problem is that most of the time, angiograms on people without chest pain symptoms show nothing. Even when there are some symptoms, the angiogram is just as likely to turn up clean as a whistle, or with only minor narrowing, as it is to show serious disease.

A new study in the New England Journal of Medicine of 400,000 patients found that the odds of finding operation-worthy heart disease in patients getting a first-time angiogram without any known heart disease was only four in ten -- which means that the $2,500 procedure was wasted on six of every ten patients.

Now, you might think that the angiogram can still be worthwhile if it shows some blockages that can be cleaned out. But that's true ONLY IF those blockages are causing symptoms. The usual technique to unblock arteries -- with a balloon and a wire scaffolding (stent) to hold open the artery -- has been shown to work to relieve symptoms of chest pain, but it does NOT extend life in symptom-free patients. In those patients, it's thought that the heart has already learned how to deal with the blockage by shifting blood from another supply.

Here is a very good article from Harvard Medical School on who should get the balloon treatment -- called angioplasty -- and who shouldn't.

The bottom line: Angioplasty can save your life during a heart attack if it can be done fast enough to open the artery before permanent damage is caused to the heart muscle. But for symptom-free patients, angioplasty is worthless and exposes patients to the risk of dying from a complication of having wires and tubes poked into your heart. And for patients with non-debilitating chest pain, angioplasty doesn't work any better than taking drugs and making lifestyle changes.

People who get chest pain and learn they have heart disease should think of the pain as a gift from on high: It's given them a chance for a new lease on life. But for people like my friend whose first symptom is a fatal heart attack, there's not much that medicine can do. We're all fated to die at some time, and we haven't learned how to defeat fate. We can and should pay close heed to getting plenty of exercise, eating right and doing other things to lower our risk. But the risk will always be there.

The man who discovered the PSA test for prostate cancer now says the test is so overused it has become a public health disaster with an annual price tag of $3 billion in wasted testing.

Dr. Richard Ablin writes an op-ed piece in the New York Times calling for the test to be abandoned for routine cancer screening for men over age 50. At most the test is useful in men with a family history of prostate cancer and also useful to detect cancer coming back in men who have already has their prostates removed for cancer.

Dr. Ablin notes that the appropriate use of the test is a tiny portion of the amount of testing now occurring, driven by those who profit from use of the test. He concludes:

I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

As this blog noted in an entry a year ago, large studies have been published showing that the PSA test saves very few, if any lives, when used for routine screening, and it causes many men to undergo unnecessary, painful and potentially harmful biopsies and surgery.

The political brouhaha that followed the new guidelines on mammograms has now died down, maybe enough so that patients can start to absorb the quiet truth about breast cancer and the role of mammogram screening.

The National Breast Cancer Coalition has worked since 1991 to get Congress to fund research and appropriate treatment for this disease. The Coalition believes in sticking to the facts and analyzing closely the research studies that have been published about what mammograms can and cannot do for women who aren't aware of a lump in their breasts.

Here is an excerpt from their discussion of the US Preventive Services Task Force recommendations:

Has breast cancer screening had a significant impact on mortality from breast cancer?

No, over 40,000 women continue to die of breast cancer each year, despite the emphasis on breast cancer screening in our country. To change this, we must address the facts about breast cancer and not simply accept what we want to believe. The fact is that all breast cancers are not equal and that we don’t currently have tools for “early detection” that are good enough for the life-threatening breast cancers.

But doesn’t early detection save lives?

Not necessarily. Some breast cancers are slow-growing and have a good prognosis, whenever they are found, whether small or large. Other breast cancers are aggressive and fast growing, and we don’t have the tools to catch them early enough or treatments that will work.

Why doesn’t mammography work as well for women in their 40s?

Younger women have more dense breast tissue, making mammography less accurate. Also, mammography is better at detecting slower growing tumors more common in older women, than the fast-growing, aggressive tumors more often found in younger women. And the balance of benefit vs. harm changes as women get older since the likelihood of breast cancer increases with age. The disease is relatively rare in younger women.

But shouldn’t a woman in her 40s have a mammogram if she feels a lump?

Certainly. The Task Force recommendations are meant to be guidelines for broad public health policy for healthy women with no symptoms, and an average risk for breast cancer. These guidelines are not meant for any woman with an increased risk or for any woman who feels a lump or change in her breast. Women who have any concerns need to visit their doctors and may need diagnostic mammograms. Mammograms taken to assess a problem are not the kind of mammograms we are talking about with these guidelines.

What’s the harm in trying to detect breast cancer early, even if our methods don’t work that well?

The harms from screening too early or too often include increased false positives, leading to increased imaging and radiation exposure, biopsies and scarring that can affect the accuracy of future mammograms, and anxiety. There is also the harm of overdiagnosis of breast cancer. This would involve treatment of cancers that would never be life threatening, and treatment of cancers that may regress, or go away on their own. The treatments for breast cancer are not aspirin, they are toxic and can be life threatening; the scenario of overdiagnosis should not be taken lightly.

The cancer coalition supports the Task Force's recommendation that women who are not in a high risk category (from a family history or presence of the BRCA gene) start thinking about mammograms around age 50, not age 40.

Here is another useful summary from the National Breast Cancer Coalition: 31 Myths and Truths about breast cancer. You can read it here.

We have discussed the statistics behind breast cancer screening in several entries on this blog. Read them here and here and here. My belief is that women need to understand the numbers and then make a personal choice. Politicians don't need to enshrine mammograms as some sort of constitutional right, as happened in the US Senate not long ago. We need more compelling evidence before this screening device goes onto the "do not touch" pedestal.

The new breast cancer screening guidelines demonstrate yet again why savvy patients need to understand the numbers behind risk/benefit studies before making the very personal decision about whether and how often to get a cancer screening test.

The recommendations of the U.S. Preventive Services Task Force that women hold off on routine mammograms until age 50, and then get one every couple of years instead of every year, are based on sophisticated statistical modeling that aimed to get the most benefit at the least harm. The benefit is saving lives. The harm is overdiagnosing, overtreating, and needlessly frightening women who receive "false alarms" with mammograms.

The key fact that women -- and all patients -- need to understand is that your risk of a "false alarm" depends on your risk for the disease. The lower your natural risk of disease, the higher the risk of a false alarm, and vice versa. The reason the task force said that women between ages 40 and 49 don't need screening is that with the low risk of disease in that age group, the chance of needless false alarm is much higher, and the benefit of discovering the occasional cancer is much lower.

For example, one statistical model, called the Stanford model, which the task force looked at, concluded that if women between ages 40 and 69 got mammograms every year, there would be on average 2,250 false alarms -- "false positive" results -- in every 1,000 women -- an average of two per woman tested over ten years. On the other hand, there would be a total of 164 years of life gained among these 1,000 women. When the mammograms were reduced to every other year, and only given between ages 50 and 69, the years of life gained were 99 and the false alarm rate went down to 780 per 1,000. That is the tradeoff.

Those extra 65 years (164 versus 99) of life gained among the 1,000 women also come at an economic cost: if 1,000 women have to get 10 mammograms each over 10 years, that cost is around $10 million (assuming $1,000 per mammogram).

We don't like to think about "rationing" medical care, but sensible decisions on both a personal and societal level have to take into account how much we're spending for how much gain, and what else the same amount of money could be spent on.

In my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," I have an extensive chapter on the risks and benefits of breast cancer screening at different ages. Here is an excerpt:

What about saving lives with screening tests intended to catch early cancers? Here is how that statistic of a 25 percent reduction in deaths translates in the real world. If you thought that means that of every 100 women screened, 25 of them would be saved by mammograms, you would be making a natural assumption that many others have made, but you would be very far off the mark. The actual numbers come from a series of studies in Sweden involving some 280,000 women. Of those over age forty who did not undergo mammograms, 4 in 1,000 died of breast cancer over the ten years of the study. Of those over age forty who did have mammograms, 3 in 1,000 died of breast cancer over the same ten years. The reduction from 4 to 3 per 1,000 is where the 25 percent number comes from. Put another way, for every 1,000 women who participate in mammogram screening for ten years, 1 of them will be saved from dying of breast cancer.7 The odds of saving 1 life are a little improved if screening begins only at age fifty instead of forty. Of every 270 women who start screening mammograms at age fifty and undergo one every other year for the next twenty years, 1 life will be saved—or about 4 in 1,000, which is a lot more than the 1 in 1,000 lives saved for starting mammograms at age forty.

The new statistics from the Preventive Services Task Force concluded that the benefit from mammograms in women aged 40-49 was even lower than the Swedish estimates -- more on the order of one life saved for every 1,900 women screened, instead of one in 1,000.

Here's the bottom line, as I put it in my book:

Are those kinds of odds worth it to undergo the trouble of regular screening? That is a personal decision. My only point is that to make that decision rationally and realistically, you need to look at the numbers with eyes wide open.

I took a deposition a few days ago that underlined for me why we need to have public report cards on primary care doctors so that patients can separate the mediocre practitioners from the really good ones. I wrote an article explaining the idea. Read my entire piece on Huffington Post, which I called "One Good Reason to Get Mad About Health Care."

Swine flu testing is the latest example of an important issue for informed patients. Patients need to understand that some medical tests are valuable if there is a "positive" finding, but not much good at all if they are "negative." The problem is that the test is "insensitive," which means a negative result can miss the disease that's really there -- a "broken alarm."

For swine flu, in every 100 patients who actually have flu, the various brands of "rapid flu" tests will have a "positive" result (meaning the patient has the flu bug) for as few as ten of the 100 patients, or as many as 69 of the 100 patients. Even with the higher accuracy, that means that a lot of patients are being missed by these "rapid flu" tests. These statistics come from a New York Times article quoting newly published studies and experts in the field including the Centers for Disease Control and Prevention.

A CDC official told the Times:

“We’re saying you need to understand the limitations of these tests,” Dr. Timothy M. Uyeki, an author of the C.D.C. guidance, said in an interview. “The clinician should not base a decision to treat or not treat on the basis of a negative result.”

Another classic example of an "insensitive" test is the "hemoccult" test for hidden blood in the stool. If it's positive, you need further workup. If it's negative, it doesn't give you a clean bill of health for colon cancer. That's why the standard screening test for colon cancer is a colonoscopy, which looks at the entire length of the colon with a video camera.

My book "The Life You Save" has a chapter about understanding medical testing and why you cannot necessarily rely on a negative test result.

The point is: A negative result doesn't mean you have a clean bill of health. Sometimes you have to pay attention to other signs and symptoms.

Imagine if every 50-year-old woman thinking about whether to have a mammogram received the following "balance sheet" showing the "credits" and "debits" as understood by the latest research:

For every 1,000 women who have a yearly mammogram over the next ten years: Credits

1 woman will avoid dying from breast cancer

Debits
2-10 women will be overdiagnosed and treated needlessly

10-15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis

100-500 women will have at least one "false alarm" (about half of these women will undergo a biopsy)

These numbers appear in an editorial in the British Medical Journal in July 2009, written by Dartmouth researcher H. Gilbert Welch, M.D., in response to news that the British National Health Service had scrapped a proposed pamphlet that would have described the benefits of mammograms, but failed to talk about their downside.

The key comparison in the above balance sheet is the ratio of one woman's life saved for every two to ten lives harmed by overdiagnosis. The one-to-two ratio comes from a study three years ago by Zackrisson and colleagues. The one-to-ten ratio is from a more recent study by Gotzsche. The tipping point for women in deciding whether to undergo annual mammogram screening is probably somewhere on this sliding scale. The test might not feel worthwhile if ten women are hurt for every one helped, but might seem worth it if only two were hurt for every one helped.

As the author writes:

Mammography is one of medicine’s "close calls"—a delicate balance between benefits and harms—where different people in the same situation might reasonably make different choices. Mammography undoubtedly helps some women but hurts others. No right answer exists, instead it is a personal choice.
To inform that choice, women need a simple tabular display of benefit and harms—a balance sheet of credits and debits.

Unfortunately, medicine hasn't yet pinned down the precise numbers on the balance sheet. For now, women need to be informed that there are varying estimates, and they need to make their own decisions.

Readers should note that this discussion applies only to cancer screening in low-risk women who have no noticeable lumps; women who can feel a lump in their breast are in a different risk category and need to see a doctor promptly.

Everyone has seen the ads: for cancer of the breast, prostate, colon and now thyroid cancer -- urging Americans to get a test to see if they have cancer and can get early life-saving treatment.

The new thyroid campaign says: "Don't forget to check your neck." However, it's a rare disease that kills about 1,600 Americans a year, but that many millions now may worry about because of this well-meaning campaign.

The trouble with cancer screening, as previously discussed in this blog about mammograms and prostate cancer PSA screening, is that in completely healthy people who have no symptoms and no special risk factors, screening can turn up far more false alarms and bring about dangerous and unneeded treatment, than the good that is done when a few cancers are caught.

A new article by Natasha Singer in the New York Times makes this point about the new thyroid media campaign, plus a proposal by Florida Congresswoman Debbie Wasserman Schultz to spend $45 million in federal money on a campaign to teach women under age 40 about how to examine their breasts. Critics of that proposal, including cancer surgeon Susan Love, say there is no benefit in early testing of women in their 20s and 30s for breast cancer. Dr. Love wrote the congresswoman: "Once you have made women more 'aware' of their potential risk, you will have nothing to tell them to do!"

The U.S. Preventive Services Task Force, a group of independent experts, recommends routine screening for only a few kinds of cancers, and breast mammograms for women under age 50 are the weakest of their recommendations. According to the article:

for otherwise healthy people with no symptoms,[Dr. Ned Calonge, chairman of the Task Force] said, only a few routine tests have proven to significantly reduce cancer deaths among certain age groups. The task force recommends pap smears for cervical cancer beginning no later than age 21; regular mammograms to screen for breast cancer in women starting at age 40; and tests for colon cancer starting at age 50. And the task force notes that the evidence supporting the breast cancer screening is not as strong as for cervical and colon cancers.

Most other types of screening, meanwhile, have not been proved to reduce the death toll from cancer, said Dr. Kramer at the National Institutes of Health.

“You need a high bar of evidence to start advertising screening to healthy people, most of whom will not benefit,” Dr. Kramer said.

One important caveat: Nobody should ignore symptoms. Once something bothers you or changes or seems unusual, you are no longer in the category of routine screening. Your risk is much higher and you should be checked promptly.

I discuss the reality behind cancer screening numbers in Chapter 8 of my new book on health care, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst." The title of Chapter 8 is: “Should I Be Tested?” Why Understanding the Numbers Is Crucial.

A good book entirely focused on this topic is by Dr. H. Gilbert Welch of Dartmouth, called "Should I Be Tested for Cancer?: Maybe Not and Here's Why."

Evidence continues to pile up for why patients need to read their own medical records. A new study finds it is distressingly common for primary care practices, especially big ones, to fail to inform patients about abnormal test results.

The study was published in the Archives of Internal Medicine and was reported by Nicholas Bakalar in the New York Times. The study was also featured in Tara Parker-Pope's "Well" blog at the Times, which features a number of horror story comments by readers.

Overall, the study found seven times out of 100, abnormal test results were not conveyed to patients. In two large primary care practices, one in four abnormal test results were never mentioned to the patient.

Bottom line: Patients who don't hear back the results of their testing can never assume that no news is good news. People need to ask for a copy of their test results from either the doctor's office or the lab where the test was done.

Getting and reading your own medical records is Step One in the nine-step system I recommend for getting the best medical care, in my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

The received wisdom of cancer treatment in the United States is that early detection and early treatment save lives. But this is not always true with some types of cancer. Sometimes the early detection of a cancer just means the patient lives longer with the knowledge of having cancer, but their life span is the same as it would have been with later detection.

A new study of women with ovarian cancer has found that women who undergo blood tests every few months to check for early signs of recurrence of the disease do not live any longer than women who wait until they feel symptoms from the cancer's return. The test is called CA125.

As reported by Andrew Pollack in the New York Times, the new study was presented at the annual meeting of the American Society of Clinical Oncology.

The reason that the CA125 test doesn't help is that some cancers are resistant to chemotherapy, so whenever treatment is started, it doesn't matter, and others are very sensitive to chemotherapy, so that they can be knocked back whether treatment is started early or a few months later. This is according to the lead author of the study, Dr. Gordon Rustin of the Mount Vernon Hospital in Middlesex, England.

Peace of mind is an important related issue. A lot of patients experience anxiety when they are waiting for the results of the periodic tests. For some, the knowledge makes them feel in control; for others, the anxiety is too much and they would prefer not to know. So getting the test becomes a very individual decision.

If you are pregnant and experiencing fatigue, dry skin, sleep loss, or weight loss, it may be worthwhile to find out whether you are a candidate for a thyroid test – these symptoms, while common in pregnant women, may be caused by underactivity (hypothyroidism) or overactivity (hyperthyroidism) of the thyroid gland.

If untreated during pregnancy, both conditions have been shown to result in higher risks for miscarriage, premature birth, preeclampsia, and even impaired intelligence in the child (in the case of hypothyroidism). But does such risk necessarily warrant a universal recommendation for thyroid tests in pregnant women? Ingfei Chen explores an ongoing debate on this issue in a New York Times article.

The thyroid gland produces hormones that regulate many important aspects of our bodies, including metabolism, body weight and heart rate. When there is too much of this thyroid-stimulating hormone (TSH), the pregnant woman suffers from hyperthyroidism and experience poor sleep, weight loss, and nervousness after giving birth. On the other hand, when the thyroid gland is underactive, the resulting hypothyroidism causes fatigue, weight gain and dry skin. Both conditions are manifested in very subtle symptoms but are risk factors for dangerous pregnancy complications.

While both an overactive and an underactive thyroid spell trouble for pregnant women, hypothyroidism is the more common and worrisome condition. Hypothyroidism, affecting 10 to 20% of women of childbearing age, is often undiagnosed but hampers fetal brain development. A study done 10 years ago reports that 19% of children born to women with untreated hypothyroidism had an IQ of 85 or lower, whereas the same measure was only 5% for those born to mothers with a healthy thyroid.

Although risks of an imbalanced level of TSH are known, the medical field is currently split on whether there is sufficient existing evidence for the benefits of treating the condition, and subsequently, of recommending universal screening. Studies are underway to track pregnant women with healthy and underactive thyroids, and their children will be tested for IQ. Until scientists arrive at conclusive results, the general clinical policy is to recommend a thyroid test to high-risk women (for example, a woman with family history of thyroid problems). However, more doctors have begun recommending the test to normal-risk expecting mothers, and many think that evidence for universal screening will soon be available, according to Dr. Stagnaro-Green, an endocrinologist at Touro University College of Medicine in New Jersey.

Widely hailed for saving lives through early detection of breast cancer, mammography may in fact “do more harm than good,” writes Roni Rabin of the New York Times. Rabin reports that British health care advocates and experts complained in a letter to The Times of London that candidates for mammography receive informational fliers that exaggerate the exam’s benefits and neglect to advise patients of potential harms.

Mammography detects cancers indiscriminatingly, picking up aggressive tumors as well as those so slow-growing that they present no health risks for women who have them. As a result, for every woman saved from deadly breast cancer by routine mammography, at least one other woman would have her life unnecessarily disrupted by overtreatment of a slow-growing cancer that’s not life-threatening.

Mammograms also often result in "false positive" reports which scare women who think the test has shown they have a deadly cancer when further testing shows they have no disease. This is particularly a problem when mammograms are used in low-risk groups like women under age 50.

Further, early detection of the deadly form of breast cancer may not necessarily be life-saving, says Dr. Ned Calonge, chairman of the United States Preventive Services Task Force, which writes consensus reports on all sorts of screening tests, because the cancers are too aggressive to treat even when found early.

In addition to unnecessary emotional distress and extraneous treatment and related costs, other potential harms of mammography include exposure to radiation during the exam.

On the other hand, many doctors, including the director of cancer screening for the American Cancer Society, still believe mammography should be recommended to women of normal risks for breast cancer (e.g. over 50 years of age, family history of the cancer), preferring overdiagnosis to delayed diagnosis.

Before a more definite conclusion is reached within the scientific community, patients should educate themselves about the benefits and harms of mammography, because the ultimate decision of whether to be screened is in their own hands.

The PSA screening test for prostate cancer causes far more men to undergo unnecessary and harmful treatment than it saves lives, according to two large new studies. As reported by Gina Kolata in the New York Times, one study that followed 77,000 American men for a decade found zero benefit in lowered death rates, while the other study, which followed 182,000 Europeans for nine years, found that only seven lives were saved for every 10,000 men screened with the blood test.

And for every one of those saved lives, forty-eight men were told they had cancer and underwent unnecessary treatment. That treatment can cause impotence or incontinence if it involves surgery, or problems with bowel elimination if it involves radiation.

The problem is not so much the test but the disease. Prostate cancer is usually very slow to grow, and in the cases where it is aggressive, it may already be too late to save the patient when it is discovered.

Both studies were published in the New England Journal of Medicine.

The same issue, on a less dramatic scale, applies to mammography screening for breast cancer. According to Dr. Michael Barry, who wrote an editorial in the NEJM accompanying the research studies, about ten women receive a diagnosis of breast cancer and undergo needless treatment for every one woman whose life is saved after having a mammogram. Breast cancer is much more dangerous than prostate cancer, so screening can still be warranted.

What doctors need, and still do not have, is a way to sort out cancers that would be deadly without treatment from those that would not.

The bottom line for patients is to ask careful questions of your doctor and understand the numbers before you decide whether cancer screening is right for you. Patrick Malone's new book, The Life You Save, has a chapter that helps patients sort through the statistics of cancer screening.

It's always intimidating to undergo an MRI scan or CT scan. The machines are loud and enormous and seem to swallow your body. For all the trouble and expense, patients deserve the very latest scanning equipment and should have their images read by only the most highly qualified doctors. Alas, there is a quiet scandal in the $100 billion/year medical imaging industry. Patients cannot count on the best unless they insist on it.

As quoted by Gina Kolata in the New York Times, radiology leaders say, in the words of one: "The system is just totally, totally broken." That from Dr. Vijay Rao, chair of radiology at Thomas Jefferson University Hospital in Philadelphia. One big problem is that insurers pay standard rates for scans, even if a scan on a 10-year-old machine produces a blurry image and results in patients undergoing unnecessary surgery or missing a diagnosis. There is also no financial incentive for scanning facilities to have the images interpreted by sub-specialists with more expertise in the body part being studied. But there is a big financial incentive for doctors to own their own scanning equipment, and that results in many unnecessary referrals for scans when the doctor's judgment about the patient's needs is clouded by financial conflicts of interest.

Wise patients should ask pointed questions before submitting to any imaging scan. Here is a list, adapted from Patrick Malone's new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, available at Amazon.

1. Is the scanning machine the latest generational available? If not, is there another facility nearby that has the latest generation? (In MRI scans for example, the stronger magnets on newer machines make for crisper images.)

2. Does the doctor who wants me to have this scan own the scanning equipment or the scanning facility? (If so, get an opinion from another doctor with no financial interest about whether you need the scan at this facility.)

3. Who will interpret the images? Is that doctor a sub-specialist in what's being studied? (Examples of radiology sub-specialties include musculo-skeletal, neuroradiology (brain and spine), abdominal and chest.) If not, can we get a second reading from a sub-specialist?

4. Is the scanning facility accredited by the American College of Radiology? (This ensures that basic standards are met, such as the technologist who runs the scanning machine being certified and the machine being regularly inspected for proper functioning.)

Involved patients will also want to sit down with the doctor and look at the images together. You will notice how much more detail comes out when the scan has been done on an up-to-date machine by well-trained personnel. In the New York Times article, you can see in a knee scan how the ligament is blurry on the left-side image but comes out clearly in the image on the right -- a slanting striated structure that connects the middle of the top of the tibia to the back of the femur.

One of the less common forms of cancer, oral cancer was diagnosed in about 35,300 Americans last year and caused the death of 7,600 people. Although oral cancer is one of the easiest to detect and diagnose, the five-year survival rate is only 59%, and more than 60% of cases are diagnosed in the late, incurable stages – which may be a result of people not regularly visiting their dentists or not asking to have visual exams, reports Laurie Tarkan of the New York Times.

The most effective way to screen for oral cancer is to carefully look for it. The dentist or dental hygienist should examine the cheeks, the gums, the floor of the mouth, the area behind the teeth, the palate and the tonsil area (pulling the tongue forward), and should feel the lymph nodes of the neck. Such visual exams are found to reduce mortality by 34% in a study done in India. Emerging on the market are alternative tests and devices that may be more sensitive than the traditional visual exams. However, no decisive study has been done to prove that the more expensive tests are necessarily better.

Dentists encourage patients to get a thorough visual exam every year, and they recommend it not only to the high-risk groups (smokers and heavy drinkers) but to every adult, because oral cancer has recently been linked to oral HPV, which is transmitted through oral sex.

Colonoscopy is widely known as a powerful screening/early detection test for colorectal cancer, capable of preventing, or so it was thought, up to 90% of cancers. However, recent studies show that colonoscopy misses many cancers, according to the New York Times in an article by Gina Kolata.

A newly published Canadian study documents the low success rate of colonoscopy in picking up cancer in the right side of the colon, an area where 40 percent of cancers occur. In the left side of the colon, the area directly above the rectum, where cancers should be easier to detect, colonoscopy missed a third of occurrences.

Does that mean patients should dismiss colonoscopy as an ineffective test? Quite the contrary. Although colonoscopy is now found to prevent only 60% of colon cancer deaths, it’s still “a good test,” said Dr. Ransohoff, gastroenterologist at the University of North Carolina. In the Times article, Kolata points out that colonoscopy works relatively well, in contrast with other screening tests: Mammograms prevent 25 percent of breast cancer deaths and the Prostate-Specific Antigen (PSA) test has not been proven to prevent prostate cancer deaths.

In addition, patients can help maximize colonoscopy’s effectiveness by doing their homework. Dr. Douglas Rex, Indiana University’s director of endoscopy and professor of medicine, said that polyps in the colons may be obscured if patients did not thoroughly cleanse the bowels. Taking half of the laxative the night before the test and the other half in the morning – a procedure not always done – can help clear out patients’ systems and improve the visibility of the inner wall of the colon.

Researchers also urge patients to seek out the best colonoscopists who are skilled in performing the test consistently. Patients should ask how many colonoscopies the doctor does each year (a good volume would be three to four colonoscopies a day), what percent of those turn up polyps (it should be around 25% in men and 15% in women; much lower suggests that the doctor is missing some), and how long the scope is in the colon (colonoscopists should take at least eight minutes to withdraw the endoscope; too short a time suggests a hurried look).

A torn meniscus that shows up on the MRI scan may not be the reason why your knee is hurting. For Cheryl Westein, who demanded an MRI and saw a torn cartilage on the scan, the culprit behind her painful knee was actually arthritis. Gina Kolata in a New York Times article reports recent scientific findings that further support what many physicians already believe: radiological imaging is a presurgical tool and “does not help with a diagnosis.”

Dr. Felson and Dr. Modic, in their separate studies, found that abnormalities in scans are common and are not conclusive evidence of a diagnosis. For example, 60 percent of healthy people who do not complain of back pain will turn out to have degenerative changes in their spines. Many abnormalities go away on their own in a few months, requiring no medical intervention.

Relying on scans for diagnoses can lead referring physicians to recommend “unnecessary or sometimes even harmful treatments, including surgery.” If the root cause of the knee pain is arthritis and not the torn meniscus, the pain will return even after a surgery repairing the meniscus, as the arthritic bones continue to wear down the cartilage.

It is important for patients to know that getting radiological imaging is often not the best way to find out what is causing their discomfort. More importantly, since scans reveal abnormalities that may not be “catastrophic findings”, doctors could be misled to recommend harmful regimens that result in extra expenses.

Patients who go in for MRIs are often told nothing is wrong, when in fact the scan is of poor quality and so misses the problem, as Gina Kolata's story demonstrates.

Doctors all agree that it is a good idea to get MRIs and other scans done at centers accredited by the American College of Radiology. But, they caution, there is a wide range of quality among those centers. Quality depends on the quality of the imaging coils put around the body part being scanned, the skill of the technicians and the expertise of the doctor reading the image:

At Massachusetts General Hospital, for example, Dr. Gazelle said, “musculoskeletal M.R.I.’s are read by someone who does musculoskeletal imaging every day” — and not “by someone who reads chest M.R.I.’s one day and musculoskeletal M.R.I.’s the next.”

Dr. Forman says it pays to check the credentials of a center’s radiologists.

“If you say, ‘Who will be reading my scan?’ and they say, ‘One of our radiologists,’ you don’t go to a place like that,” he said. (I checked the Web site of the first center I went to. The radiologist who read my scan was a generalist with no special training.)

It also pays to ask the radiology center whether it has the latest generation of scanners. The stronger the magnet in the MRI machine (the "M" in MRI stands for Magnetic), the higher quality the image it produces.

Misreadings of MRI scans can cause tragic, preventable injuries to patients, as our firm's experience has shown.

The other piece of advice we can extract from the article is not to place absolute faith in a first-time scan that turns out negative. If the scan is negative and you feel that something is still wrong--like there is still severe pain--it is worthwhile to get a second opinion.

An online service called inSPOT allows patients who test positive for STDs to use a website to notify sexual partners, anonymously if they so choose, of the possibility that the partners were infected. A report done by the San Francisco Department of Public Health finds that since 2004, 30,000 people have used the service to send 50,000 notifications of all sorts of diseases contracted through sexual activity.

This project has enormous potential health benefits because embarrassment and a desire to remain anonymous are factors that can prevent people from notifying past sexual partners of their risk of contracting the disease. Of course, as Dr. Richard Rothenberg of Georgia State University notes in the article, it is difficult to track the effects of the project because of confidentiality issues. Nevertheless, the project is valuable:

However, it may be difficult, if not impossible, to study the impact on health because the service is confidential, Rothenberg said. "I think we, and the authors, must be content with the idea that this appears to be an acceptable method to fulfill the moral imperative of notification, and it has a chance to be a better approach than what we currently do," he said.

A new LabCorp blood test called OvaSure is aimed at early detection of ovarian cancer, but OB-GYNs doubt its efficacy and safety, as false positives might lead to unnecessary surgery and extreme anxiety. Ovarian cancer often goes undetected until later stages, by which point it can be too late to treat it effectively. A test that makes early detection more feasible would therefore be a wonderful thing.

From the article:

The need for such a test is immense. When ovarian cancer is detected at its earliest stage, when it is still confined to the ovaries, more than 90 percent of women will live at least five years, according to the American Cancer Society. But only about 20 percent of cases are detected that early. If the cancer is detected in its latest stages, after it has spread, only about 30 percent of women survive five years.

But far from greeting the new test with elation, many experts are saying it might do more harm than good, leading women to unnecessary surgeries. The Society of Gynecologic Oncologists almost immediately issued a statement saying it did not believe the test had been validated enough for routine use.

“You’ve got industry trying to capitalize on fear,” said Dr. Andrew Berchuck, director of gynecologic oncology at Duke University and the immediate past president of the society. “We’d all love to see a screening test for ovarian cancer,” he added, “but OvaSure is very premature.”

The test is good news if it is indeed valid, but raising false hopes and causing unnecessary procedures and stress is an adverse consequence of all this hype.

The NY Times Well blog has a podcast of Dr. John Hickner, professor of family medicine at the University of Chicago, discussing why patients should always call their doctors to follow up after having a medical test done.

We have previously discussed the issue of medical test results getting lost in transmission: the patient will expect the doctor to call if there is bad news, and will feel reassured if he or she hears nothing, while the doctor's office will wait for the curious patient to contact them, or will simply forget, and the patient "falls through the cracks." As a result, the patient may not hear about important test results.

The best way for patients to deal with this is to remember to call their doctors after testing and keep in mind that no news is not necessarily good news.

Another thing that patients can do is always ask the testing facility for a copy of the test results. Some laboratories and radiology offices resist this, but every patient has a right to their own records.

Serious injuries can happen to patients from delayed treatment due to these failures of communication, so it's important for patients to be pro-active about their test results.

A new study from the journal Quality and Safety in Health Care, and discussed in the NY Times Well blog, reveals common testing mistakes by primary-care doctors. Of course, the same kinds of errors can happen in hospitals and other health care settings.

Out of close to the 1,000 mistakes experienced by 590 patients, the following testing mistakes were the most common:

-13% involved ordering the wrong test or failing to order a test

-18% involved performing the right test, but doing it improperly

-25% involved delays in getting tests back from the laboratory, failure to get the tests back at all, or errors on the results report

-7% involved failing to follow up with patients after receiving results from the laboratory

-75% of the mistakes caused the patient to suffer (through delays in proper treatment, greater expense, physical pain or worsened overall health).

What can a patient do about this? A possible solution would be to carefully ask and write down what specific test your doctor has ordered for you. Ask when the results of the test are expected from the lab. Then make sure you call to follow up after the doctor's office should have received the results. Read the results report, if you can get hold of it, to see the name of the test and make sure that the results are for the same test that was ordered and performed. All of these things might help reduce your risk. Calling the doctor to follow up is probably the most important item on the list, as Dr. Lamberts says in his quotation in the linked NY Times blog post.

Tara Parker-Pope recently had an article on how fewer and fewer patients trust their doctors.

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins study published this year in the journal Medicine. And two recent studies show that whether patients trust a doctor strongly influences whether they take their medication.

The distrust and animosity between doctors and patients has shown up in a variety of places. In bookstores, there is now a genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease.

What are the reasons for this new distrust? Several factors appear to be involved:

(1) Patients often don't understand what is going on with their health care because doctors and nurses are too rushed to explain things to them. Dr. Sandeep Jauhar, cardiologist and author of Intern: A Doctor's Initiation, is quoted in the article with a story of a patient who was transferred from one hospital to another with no explanation for why. He blamed a "broken system" for such failures to communicate.

(2) There has been greater coverage in the news of medical error, the power of the drug industry and the flaws in health care administration.

(3) The Internet makes information much more available, so patients can be informed skeptics. Drug companies also market directly to patients, so they come into the doctor's office with their own desires and opinions on what medications they should take. The upside to this is that patients have the information to challenge a doctor's errors. The downside is that many end up taking a drug commercial, for instance, at face value and will not listen to a doctor's reservations about the efficacy of a drug.

Again, from the article:

“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”

The whole article is worth reading. In addition, the article's page also has an embedded video clip of interviews with people discussing their attitudes to their doctors.

In our previous post, we discussed Dr. Peter Bach's comments on Medicare funding for unnecessary (in his opinion) testing. In response to Bach's article on the subject, the NY Times published readers' letters, most of which were highly critical of Bach's proposals about Medicare and testing.

The first letter, from Dr. Brant S. Miller, is especially interesting because Miller argues that Bach's proposals are nothing new:

We already tried capitation with H.M.O.’s in the 1990s, and that turned out to be a disaster. The media reported countless abuses by H.M.O.’s that killed or maimed patients as the insurers paid doctors more for denying care and less for providing care. Fee for service turned into plea for service. So, here we go again.

Since the 1990s, patients have been told that your doctor is greedy and doing unnecessary tests. And by the way, you shouldn’t have to pay much out of pocket, and there shouldn’t be any forms to fill out. Meanwhile, Tim Russert dropped dead when a one-minute CT scan could have shown progression of disease in his left anterior descending coronary artery.

Another interesting letter is from professor of neurology Michael Hutchinson. Hutchinson criticizes Bach for making "sweeping statements" and corrects his portrayal of the facts regarding testing and equipment use:

In fact, an extensive study done by doctors at Massachusetts General Hospital on physician ownership of imaging equipment was published last year. The study failed to define a major increase in imaging by doctors who own their equipment compared with doctors who do not.

Perhaps this has to do with strict government regulation, but imaging costs have actually been declining in the last two years. The total cost of M.R.I. scanning is now a fraction of 1 percent of health care.

Hutchinson also points out that imaging leads to fewer hospital and emergency room visits and also fewer procedures done, which helps reduce health care costs overall.

Those two letters were intriguing, but all of the letters responding to Bach are worth perusing.

Peter Bach, former adviser to the Medicare and Medicaid administrator, wrote a NY Times op-ed arguing that the Medicare system pays doctors for how many tests they run with a given piece of equipment but not for how much time they spend with patients. Readers responded with letters on the subject.

From the op-ed:

Medicare pays doctors for specific services. If a patient has a checkup that includes an X-ray, a urine analysis and a physical, Medicare pays the doctor three separate fees.

Each fee is meant to reimburse the doctor for the time and skill he or she devotes to the patient. But it is also supposed to pay for overhead, and this is where the problem begins. To Medicare, a doctor’s overhead (or “practice expense”) includes such items as rent, staff salaries and the cost of high-tech medical equipment. When the agency pays a fee to a doctor who has performed a CT scan, it is meant to cover some of the cost of buying or leasing the scanner itself. Services using more expensive equipment generate higher fees.

Any first-year business school student can see the profit opportunity here. The cost of a CT scanner is fixed, but a doctor earns fees each time it is used. This means that a scanner becomes highly profitable as soon as it’s paid for.

In contrast, the doctor-patient visit, which involves no expensive equipment, offers no significant profit opportunity. So the best way for a doctor to make money in his practice is not to spend time with patients but to use equipment as much as possible. That means moving the maximum number of patients through the practice, and spending the minimum amount of time with each one.

Bach offers suggestions for how the system should be reformed. He also includes evidence showing the increase of testing.

The informed patient on Medicare should ask questions about exactly what tests are being performed and why, and should not be concerned with taking up too much of the doctor's time.

The NY Times has a long and informative article on the pressures physicians face to give patients with heart problems unnecessary CT angiogram scans, which are very expensive and not demonstrably more effective than cheaper tests.

Aside from the expense, the scans come with radiation exposure equal to as much as 1,000 chest X-rays.

Further, each scan creates an additional lifetime risk of cancer that is somewhere between 1 in 200 and 1 in 5,000, said Dr. David J. Brenner, director of the Center for Radiological Research at Columbia University. Younger patients and women are at higher risk.

Many patients do find it emotionally reassuring to get the results of these tests, since the CT scan allows the patient and doctor to actually see if the heart has any problems. However, perhaps part of the love of these tests stems from what Johns Hopkins professor of medicine Bruce Leff calls (in a letter to the NY Times editor) "gizmo idolatry":

As a geriatrician and health services researcher, I believe that the demand for cardiac CT scans is a textbook example of gizmo idolatry, or the implicit conviction that a more technological approach is intrinsically better than one that is less technological.

The other letters are worth reading as well.

Despite concerns about the efficacy of these tests, many doctors and patients swear by them and they will probably remain popular. As the article notes, Medicare decided to fund these CT scans despite lack of clear evidence of their usefulness, and private insurers will most likely follow suit.