‘Theater,’ video help to clarify risk-benefit of treatments like mammograms

Just as patients are unwell and struggling, their well-intentioned doctors may confront them with difficult choices about their care. They often do so with daunting data, and hard to decipher numbers that don’t really answer the vital question: How well does this treatment work, especially for me?

Kudos to two Maryland experts, internist Andrew Lazris, and environmental research Erik Rifkin, for their effort to assist patients and caregivers to “reexamine the usefulness of cancer exams, cholesterol tests, osteoporosis pills, MRI scans and many other routinely prescribed procedures and medicines.” A tip of the hat, too, to the Kaiser Health News service in tapping a useful technology−online video−to illuminate exactly what the experts are up to.

I’ve written  about the value of a metric, deeply grounded in research and sound statistics, called the Number Needed to Treat (NNT). It succinctly and powerfully answers an important question for doctors and patient-consumers: How many patients needed to be treated in a certain way for one to benefit? So, for example, 104 patients would need to take statins before just one would see benefit in prevention of heart attack; 1,667 healthy patients would need to take aspirin before just one sees aspirin’s benefits in preventing stroke or heart attack.

NNT’s are calculated carefully by researchers who pore over available studies on various therapies, and there’s a helpful website that lists this key measurement for many different treatments.

In the alternative, however, too many patients get dazed by doctors tossing numbers at them, Lazris and Rifkin say. KHN, for example, cites one timely example−worth discussing more in a second−involving mammograms. The screenings, often “are said to cut the risk of dying from breast cancer by as much as 20 percent.”

That sounds impressive until Lazris and Rifkin, with the nifty illustrative approach of their “benefit-risk characterization theater,” walk through those numbers. Click on the video to see how the seemingly impressive statistic diminishes under the glare of tough-minded analysis.

This doesn’t mean, the experts underscore, that they’re trying to interpose themselves in the difficult discussions and decisions between doctors and patients about care. But they say they want patients to make shared, informed choices about what can be life and death matters affecting them.

How much does a theatrical approach to health data matter? Stat, the online health information site, has reported on a new study, published in the peer-reviewed and highly respected New England Journal of Medicine, that sheds a harsh light on the possible over-promotion of mammograms. As Stat summarizes it:

For every woman in whom mammography detected a breast cancer that was destined to become large and potentially life-threatening—the kind that screening is intended to head off—about four are diagnosed with one that would never have threatened their health. But the surgery, chemotherapy, or radiation that follows such diagnoses can be traumatic, disfiguring, toxic, or even life-shortening even as it’s unnecessary.

Unlike previous research suggesting more mammography benefits, the latest work relies not on mathematical models but analysis of actual patient data, “records of breast cancers diagnosed in women 40 or older during two periods, 1975 to 1979, before mammography became common, and 2000 to 2002.”

The lead researcher, Dr. H. Gilbert Welch of the Dartmouth Institute, tells Stat: “Mammography can help a few—a very few—women, but it comes at a real human cost, including people undergoing treatment unnecessarily.” He and his fellow researchers found that the reductions in breast cancer deaths that have been achieved mostly with improved drug treatment (two thirds), versus screening (one third).

I’ve written before and can’t emphasize more the importance of medical care being evidence-based and carefully considered, especially to drive down unnecessary costs, and to spare patients from the harm that can result when physicians are too eager to suggest procedures, drugs, or treatments that are unwarranted.

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