MARK YOUR CALENDARS

This Thursday, January 17th, The Texas A&M Health Science Center College of Medicine is hosting a public lecture which will be streamed live via their Facebook page.  Questions may be submitted in advance of the event OR during the talk so if you have a chemobrain like me and fear you will forget your question, follow that link and add the question now.  BEFORE you forget!  As an aside, the recorded video will be available on their You Tube channel.  In other words, even if you are not able to attend live, don't let that stop you from adding your questions or concerns.  I will be sure to provide the link as soon as it's posted.

The live stream is a first for them and they are hoping this will turn into a no-holds barred conversation and it's a topic that is of interest to many of us.  Dr. A. Nelson Avery will be discussing how cancer screening guidelines are developed, who plays roles in the development of the guidelines and how the health and well being of those who benefit from the screenings may be affected.  Is cost a factor?  Are we (not really "we" but "THEY") willing to sacrifice a couple of lives to save a few dollars?  Who is behind the decisions and are they medically sound?

The credentials Dr. Avery is bringing to the discussion can be found here.  The specifics about the topic can be found here. 

I have a horse in this race.  In fact, I have several.  And I have an ax to grind, too.  I've seen a couple of my metastatic friends chatting on their Facebook pages about "waiting for approval" for PET scans.  Or, "the PET scan was denied as unnecessary because the insurance company says the CT is sufficient."

If the technology is available, especially for those living with metastatic disease, to get excellent imaging and quite possibly a better feel for what is happening, I get enraged that the tests are being delayed or denied.  Lives are hanging on the edge of someone's pen sitting in a pile of scan requests?  UNacceptable.  Waiting for one more hour than necessary angers me.  Having someone making decisions using the equivalent of actuary charts PISSES ME OFF.

All lives matter. Every single life matters.  And care should be determined by the treatment team with the patient as an active participant.  No one else's agenda should play into these decisions.  Is the test medically sound?  Does the doctor, YOUR doctor, believe it's the best course of action?  Fine.  Game over.  No one else gets to throw their weight around. Except, that's not the reality.  That's the "Dream On" version of the program.

Here's my gripe, or more accurately, ONE of my gripes.  I know that my mom's metastasis was found using a PET/CT combination scan which I shared recently on this blog.  That was approved.  It is also cutting edge.  According to what I heard during her visit on Friday, when her three month scans are ordered, it's entirely possible a PET scan will not be authorized.  The oncologist already indicated if they won't approve a PET scan, he will proceed with a bone scan and it will be fine.

HUH?  My question?  Will it really be fine or is this just a less expensive test that may not pick up some of the more subtle nuances that may help guide the treatment decisions of our oncologist.  If our very excellent oncologist is doing what he does, quite excellently with a difficult diagnosis, is anyone tying one hand behind his back?  If so, who IS that person because I'm prepared to raise the roof and bang on doors if I get ANY sense that is what is happening.

I will be damned if I'm going to allow some unknown person sitting at a desk five states away read a chart and make a decision.  You are five states away and you are NOT part of the treatment team.  Step out of your office and show me your face.  Me, my mom, my friends... we are not "cases" on the paperwork being reviewed by a total stranger whose sole concern is the bottom line.  We are people, in need of routine screening for preventative measures and some are in need of screening to ascertain treatment protocols are working.

If you have questions you would like to see discussed, feel free to leave them in a comment here and I will pass them along to Dr. Avery and his team.   

For my non-clickers....  This is what Dr. Avery hopes to share with us:

Each year, around 350,000 people are diagnosed with breast, cervical, or colorectal cancer in the U.S., and nearly 100,000 die from these diseases. Trials show that early detection can reduce mortality rates. What could be wrong with screening, especially if it can detect a life threatening condition at an earlier stage? Why recommend against screening unless the concern is cost? Are lives lost to save money? What are the real reasons that guidelines set limits on screening? We’ll discuss how cancer screening guidelines are developed in the U.S., why there is disagreement on some of them, and their impact on healthcare delivery.

Interestingly enough, as I found out about this lecture, THIS hit my news feed via Medscape.  Although the wording says "risk" isn't worth the benefit, I'm left wondering if they really meant to say the benefit isn't worth the cost.  And frankly, that's UNacceptable.

From  Medscape, an impossibly annoying mess of numbers.  The emphasis on ONE death not being good enough, go tell that to the grieving family and then, get back to me with the nonsense about harms outweighing benefits.  Sounds like a convenient excuse to refuse a test.  And yes, some things are just that simple.  And things like this should not be guiding anyone's treatment options or precluding them from a test their doctor feels is the right course of action.  Whomever is behind this, kindly step the hell aside.  YOU are standing in the way of progress.

Medscape:

Screening for breast and colorectal cancer should be targeted at individuals who have a life expectancy greater than 10 years. Otherwise, the harms may outweigh the benefits of screening, according to a study published online January 8 in BMJ.

This conclusion comes from a meta-analysis of survival data from Denmark, Sweden, the United Kingdom, and the United States conducted by Sei J. Lee, MD, assistant professor of medicine at the University of California, San Francisco, and colleagues.

The researchers found that in populations primarily older than 50 years, it took an average of 4.8 years to prevent 1 death from colorectal cancer in 5000 people undergoing of fecal occult blood test screening.

This suggests that the harms of screening outweigh the benefits for most people with a life expectancy of less than 5 years. In addition, it would take 10.3 years to prevent 1 death from colorectal cancer for every 1000 patients screened, which indicates that for most people with a life expectancy greater than 10 years, the benefits likely outweigh the harms.

Results were similar for breast cancer. It took 3.0 years before 1 death from breast cancer was prevented in 5000 women screened with mammography, and 10.7 years before 1 death was prevented in 1000 women screened.

"Therefore, patients with a life expectancy greater than 10 years should be encouraged to undergo screening for colorectal cancer and breast cancer," the researchers write. "Conversely, patients whose life expectancy is less than 3 to 5 years (that is, less than the time lag to an absolute risk reduction of 1 in 5000) probably should be discouraged from screening, since the potential risks probably outweigh the small probability of benefit," they explain.

However, they caution that these results should not be used to deny screening for people with a limited life expectancy. "Rather, our results should inform individualized decision making, which aims to account for patient preferences and values while maximizing benefits and minimizing risks," Dr. Lee and colleagues note.

Defining the Time Lag

The researchers analyzed the results of 5 breast and 4 colorectal cancer screening trials with populations predominantly older than 50 years. All were population-based randomized controlled trials that compared screened with unscreened populations. All of the studies were identified as high quality by the Cochrane Collaboration and the US Preventive Services Task Force.

The primary end point was the time to death from breast or colorectal cancer in screened and unscreened populations. The studies used fecal occult blood testing for colorectal cancer screening and mammography for breast cancer screening.

The researchers note that screening for these 2 cancers can find asymptomatic cancer at an early stage, which, if not treated, can cause symptoms or even death years later. Therefore, screening has a "time lag to benefit" — from the screening date, when the person is exposed to the potential risks of screening, to the point when benefits can be observed in clinical trials.

However, it remains unclear just how long a person needs to live to potentially derive a survival benefit from screening. Randomized controlled trials of screening tend to focus on the magnitude of benefit, rather than when those benefits actually occur, the researchers explain, which has led to differences in recommendations about the time lag to benefit.

To determine the screening time lag to benefit, the researchers calculated the number of years needed to reach different thresholds of benefit, using the absolute risk reduction in cancer-specific mortality. These absolute risk reductions ranged from preventing 1 cancer death per 10,000 people screened to preventing 1 cancer death per 500 people screened.

They found that mortality benefits varied in the studies, but that the benefit in colorectal cancer mortality rose steadily with longer follow-up periods; at 15 years, 23 colorectal cancer deaths were prevented for 10,000 people screened.

This was also true for breast cancer screening; at 15 years, the benefit of mammography increased to 19 deaths prevented for 10,000 women screened.

They note serious harms in 3 in 10,000 people screened for colorectal cancer and in 1 in 1000 screened for breast cancer. Therefore, an absolute risk reduction of 1 in 1000 is probably a reasonable threshold at which the potential benefit will likely outweigh the potential risk in most people.