An Example of Futile Spending: Preventive Screening at End of Life

Looking at contemporary medicine’s complex landscape, especially in regard to soaring costs, can make practitioners dizzy. For example, if primary care physicians were asked whether it is cost-efficient and reasonable to screen with prostate-specific antigen (PSA) measurement for early-stage prostate cancer in men with terminal pancreatic cancer or to perform colonoscopy for early diagnosis of colon cancer in women with stage IV lung cancer, the answer would be a quick and uniform no. Unfortunately, a recent publication¹ suggests that in the real world the answer has been yes, as disturbing and wasteful as that may be.

SCREENING CONTINUES DESPITE DIMINISHING RETURNS
The benefits of cancer screening are unquestioned, but only in the appropriate populations-those persons who can derive a discernible benefit from the early diagnosis of cancer. On the other hand, a precancerous polyp uncovered at colonoscopy or a stage I prostate cancer discovered by an elevated PSA level will not cause the death of someone who survives only months consequent to a previously diagnosed, advanced malignancy.

Sima and colleagues¹ focused on patients with the following poor prognostic diagnoses: stage III B to stage IV lung cancer or advanced pancreatic, breast, colorectal, or gastroesophageal cancers. The disease entities selected were associated with a high likelihood of death within a year or two. The screening tests for early, additional cancers and cardiovascular prevention reviewed were mammography (used as a screen for 8.9% of the advanced cancer cohort vs. 22% of controls), Pap smear (5.8% vs. 12.5%), PSA test (15.0% vs. 27.2%), lower GI endoscopy or colonoscopy (1.7% vs. 4.7%), and cholesterol measurement (19.5% vs. 37.4%). Actually, cholesterol measurement to assess cardiovascular risk was most common in the group of women who had received a diagnosis of stage IV breast cancer (32.3% vs. 54.5%). The authors’ conclusion: "A sizeable proportion of patients with advanced cancer continue to undergo cancer screening tests that do not have a meaningful likelihood of providing benefit."¹

The authors observed that both cultures involved in the study (ie, physicians and patients) might be driving this costly trend. For example, relatively affluent persons were more commonly screened, which suggests that the practice may be physician-driven. The authors also offered this caveat: in select instances, screening tests may be indicated in a similar cohort and may benefit specific patients.

AT WHAT POINT DO COSTS OUTWEIGH BENEFITS?
Cost is the thorniest issue complicating contemporary healthcare reform. The results of this study should prompt sober reflection on the wastefulness inherent in screening patients for early cancer, or long-term cardiovascular prevention, when they would be better served by palliative care.

Several recent studies have demonstrated other expensive practices that return little in terms of meaningful survival. For example, did you know that dialysis in elderly persons with dementia or systolic dysfunction does not offer significant advantages compared to conservative care without dialysis?^2,3 Dialysis also precipitates a severe functional decline in this population.^4,5 Did you know that tube feeding does not prolong life in elderly, severely demented patients at the end of life, but is applied more often in for-profit hospitals?^6,7 Did you know that a recent study comparing 2 groups with advanced metastatic non–small cell cancer (stage IV) demonstrated that those persons randomized to palliative care lived longer, spent less time in the hospital and emergency department, and had a better quality of life?⁸

The editorial on this last study said it all: "Despite the increasing availability of palliative care services in US hospitals and the body of evidence showing the great distress to patients caused by symptoms of the illness, the burdens on family caregivers, and the overuse of costly, ineffective therapies during advanced chronic illness, the use of palliative care services by physicians remains low. . . . Physicians tend to perceive palliative care as the alternative to life-prolonging or curative care-what to do when there is nothing more that we can do-rather than as a simultaneously delivered adjunct to disease-focused treatment."⁹

What is our responsibility in this medical care cost crisis associated with wasteful, non-efficacious spending? It appears that physicians and patients are fueling the waste by spending on expensive technologies that do not prolong life or add to its quality. Can we change how we do business before it is too late?

References:

REFERENCES:
1.

Sima CS, Panageas KS, Schrag D. Cancer screening among patients with advanced cancer.

JAMA

. 2010;304:1584-1591.

2.

Murtagh FEM, Marsh JE, Donohoe P, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5.

Nephrol Dial Transplant

. 2007;22:1955-1962.

3.

Brunori G, Viola BF, Parinello G, et al. Efficacy and safety of a very-low protein diet when postponing dialysis in the elderly: a prospective, randomized, multicenter controlled study.

Am J Kid Dis.

2007;49:569-580.

4.

Kurella Tamura M, Covinsky KE, Chertow GM, et al. Functional status of elderly adults before and after initiation of dialysis. 

N Engl J Med.

2009;361:1539-1547.

5.

Jassal N, Chiu E, Hladunewich M. Loss of independence in patients starting dialysis at 80 years of age or older.

N Engl J Med

. 2009;361:1612-1613.

6.

Teno JM, Mitchell SL, Gozalo PL, et al. Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment.

JAMA

. 2010;303:544-550.

7.

Finucane T. Artificially giving nutrition and fluids is not one action.

BMJ

. 2003;326:713.

8.

Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer.

N Engl J Med

. 2010;363:733-742.

9.

Kelley AS, Meier DE. Palliative care-a shifting paradigm.

N Engl J Med.

2010;363:781-782.