From PSA tests for prostate cancer (which more than 20 million U.S. men undergo every year) to surgery for chronic back pain to simple antiobiotics for sinus infection, a remarkable number and variety of tests and treatments are now proving either harmful or only as helpful as a placebo.
This realization comes at a time when Medicare has emerged as a fat target in the debate over taming the deficit, with politicians proposing to slash costs by raising the age of eligibility or even eliminating the program. Experts estimate that the U.S. spends hundreds of billions of dollars every year on medical procedures that provide no benefit or a substantial risk of harm, suggesting that Medicare could save both money and lives if it stopped paying for some common treatments. "There's a reason we spend almost twice as much per capita on health care [as other developed countries] with no gain in health or longevity," argues Dr. Steven Nissen, the noted cardiologist at the Cleveland Clinic. "We spend money like a drunken sailor on shore leave."
Many medical advances, of course, have saved lives and eased suffering for millions of people. Screening tests like mammograms can lead to early treatment of breast cancer, especially for women with hereditary risk or a strong family history of the disease. For cancer patients who report back pain, MRIs can prove invaluable for spotting tumors that have metastasized to the bones, allowing doctors to intervene before it's too late. The years between 1980 and 2004 saw a 50 percent decline in the death rate from coronary heart disease thanks to better treatments and drugs that reduce cholesterol and blood pressure. At least 7,300 lives are saved every year thanks to colonoscopies.
The dilemma, say a growing number of physicians and expert medical panels, is that some of this same health care that helps certain patients can, when offered to everyone else, be useless or even detrimental. Some of the most disturbing examples involve cardiology. At least five large, randomized controlled studies have analyzed treatments for stable heart patients who have nothing worse than mild chest pain. The studies compared invasive procedures including angioplasty, in which a surgeon mechanically widens a blocked blood vessel by crushing the fatty deposits called plaques; stenting, or propping open a vessel with wire mesh; and bypass surgery, grafting a new blood vessel onto a blocked one. Every study found that the surgical procedures didn't improve survival rates or quality of life more than noninvasive treatments including drugs (beta blockers, cholesterol-lowering statins, and aspirin), exercise, and a healthy diet. They were, however, far more expensive: stenting costs Medicare more than $1.6 billion a year.
If that finding makes you scratch your head-how can propping open a narrowed blood vessel not be wonderfully effective?-you're not alone. Many cardiologists had the same reaction when these studies were published. It turns out that the big blockages that show up on CT scans and other imaging, and that were long assumed to cause heart attacks, usually don't-but treating them can. That's because when you disrupt these blockages through surgery, you "spray a whole lot of debris down into the tiny blood vessels, which can trigger a heart attack or stroke," says Nortin Hadler, a professor of medicine at the University of North Carolina, whose book on overtreatment in the elderly,Rethinking Aging, will be published next month. Many of the 500,000 elective angioplasties (at least $50,000 each) performed every year are done on patients who could benefit more from drugs, exercise, and healthy eating.
New technology has sometimes made the problem more acute. Where once arterial blockages were detected by chest X-ray, now doctors can use cardiac CT angiography, which shows the heart and coronary arteries in dramatic 3-D. When it was introduced a decade ago to screen for cardiovascular disease, it seemed almost miraculous: a 2005 cover of Time trumpeted that it could "stop a heart attack before it happens." Difficult as it is to believe, however, there can be such a thing as too much information, especially from new imaging technology. "Our imaging and diagnostic tests are so good, we can see things we couldn't see before," says Lauer of the National Heart, Lung, and Blood Institute. "But our ability to understand what we're seeing and to know if we should intervene hasn't kept up."
In a recent study, John McEvoy, a heart specialist at Johns Hopkins Medical Institutions, and colleagues found that 1,000 low-risk patients who had CT angiography had no fewer heart attacks or deaths over the next 18 months than 1,000 patients who did not undergo the screening. But they did have more drugs, tests, and invasive procedures such as stenting, all of which carry a risk of side effects, surgical complications, and even death. The CT itself has a potential side effect: by exposing patients to high levels of radiation, it raises the risk of cancer. "Low-risk patients without symptoms don't benefit from CT angiography," says McEvoy, though high-risk patients with heart disease might.
The Cleveland Clinic's Nissen has seen firsthand what happens when doctors, armed with too much information, perform what turn out to be unnecessary procedures. In 2009 a 52-year-old woman with chest pain underwent a cardiac CT at a community hospital. Neither her LDL (bad) cholesterol nor her C-reactive protein (another risk factor for heart disease) were elevated. But since the CT showed several coronary plaques, her physicians performed coronary angiography. Complications ensued, and the woman wound up undergoing more procedures, one of which tore an artery. She eventually went to the Cleveland Clinic for a heart transplant-not because she had heart disease when it all started, says Nissen, but because of the cascading interventions triggered by the CT.
Nissen regularly counsels asymptomatic, low-risk patients against having cardiac CT, echocardiograms, and even treadmill stress tests; studies show they produce many false positives, leading to risky interventions. Even a clean scan can lead to worse health, if it makes people believe they can eat whatever they want and stop exercising. "I've had colleagues gain weight after a negative heart scan," apparently figuring they were home free, says UCSF's Redberg.
Radiologists and other physicians who diagnose or treat back pain have their own version of the CT: it's called magnetic resonance imaging, or MRI. Just as cardiac CT makes sense in principle, so does getting a high-resolution image of the spine if someone is suffering lower back pain with no clear cause. An MRI typically costs about $3,000 and is designed to spot everything from bulging discs to hairline fractures. Find any of those things, the logic goes, and you can treat the problem surgically. But there's a fundamental flaw: clinical trials have shown that back surgery, including vertebroplasty (putting special cement on a tiny spinal fracture) and spinal fusion, is no more effective at alleviating ordinary pain than plain-old rest and mild exercise. But like any surgery, it carries risks. Last year the American College of Physicians warned that "routine imaging [for low back pain] is not associated with clinically meaningful benefits but can lead to harms." That's because the "abnormalities" seen in an MRI often have nothing to do with the back pain (people without pain have them, too), but seeing something on a scan makes a physician feel compelled to get rid of it. "There is a longstanding fallacy among physicians that if you find something different from what you perceive to be 'normal,' then it must be the cause of the patient's problem," says UNC's Hadler.