Things you probably didn't know about health care...

Things you probably didn't know about health care...

This is a discussion on Things you probably didn't know about health care... within the Off Topic & Humor Discussion forums, part of the The Back Porch category; Scientific American had a very good article on Comparative Effectivenenss Research. We may actually find out which treatments really work and which don't. Here is ...

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Thread: Things you probably didn't know about health care...

  1. #1
    Senior Member Array DoctorBob's Avatar
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    Things you probably didn't know about health care...

    Scientific American had a very good article on Comparative Effectivenenss Research. We may actually find out which treatments really work and which don't.

    Here is a link to some really important articles that may siginficantly change your opinions about what and how much health care you may want for yourselves and your family.

    Sharon Begley on common myths 4 Common Health Care Myths: test Yourself: Scientific American

    John Carey on the value of cholesterol drugs Do Cholesterol Drugs Do Any Good?

    PSA testing

    PSA testing has been around for 20 years but there is still a great deal of controversy about its use as a screening device. Prostate cancer is more and more common in men as they age. but is indolent most of the time and people die with it rather than of it.

    PSA is a very imperfect screen since its value can go up for many reasons and it does not differentiate significant tumors from those that would never cause harm. This results in over diagnosis and overtreament with unecessary impotence, incontinence and rectal dysfunction.

    Among the 70% of men who are diagnosed with low risk disease, 90% are treated including 80% of those older than 75. Some clinicians feel this is 'over treatment' and drives up cost as well as harms without extending life.

    Two large well designed randomized trials were published recently. The PLCO trial showed no mortality benefit over 11 years of followup. The ERSPC trial followed men for about 9 years (median) and indicated a reduction of about 7 deaths per 10,000 men who were between 55 and 69 when they entered the study. Another study in Lancet Oncology showed a reduction of 4 per thousand (down from 9/1000 to 5/1000) over 14 years but not all the men in whom cancer was detected were treated.

    The thing that clinicians are doing wrong, is screening older men at a greater rate than younger men. It is possible that high risk men in their 40's might benefit from screening (but good info on false positives are not available in this age group). There are virtually no good data suggesting that men over 75 should be screened and the upper level of potentially useful screening may be about 65-70, if it is useful at all.

    If prostate cancer is diagnosed, physicians need to have a detailed and thorough discussion with patients about the options. Active surveillance, or expectant management, or symptomatic treatment may make a whole lot more sense than surgery, chemo, and radiation. The PIVOT trial reported about a month ago compared surgery with observation over 12 years in men with low risk tumors and/or lower PSA levels and showed no advantage with surgery. It did show a 'modest' benefit for men with high risk tumors or PSA over 10.

    An interesting study by Vickers, et al. in the British Medical Journal (2010:341:c4521) indicated that the PSA at age 60 might be used to predict the lifetime risk of metastatic prostate cancer and death. (Further study is indicated and the results need to be replicated).

    Bottom line: If you are going to use PSA at all, it should be directed at testing high risk men at younger ages; NOT repeating the test annually in men with low levels; NOT performing a biopsy based on a single high reading; active surveillance or expectant management where appropriate; and, referral to high volume surgical centers if early treatment is indicated.

    Take a few minutes with your physician to do some joint decision making about PSA testing. Personally, at my age, I've decided not to test.

    Addendum:
    The Centers for Medicare and Medicaid Services (CMS) recommended coverage for treatment with sipuleucel-T for patients with terminal proastate cancere. It extends survival by about 4 months (+/- a month) at the cost of $93,000.
    It's going to be VERY hard to prevent hyper inflation of medical care costs in a setting that utilizes such expensive medication for such a small benefit...
    Last edited by DoctorBob; June 18th, 2011 at 01:55 PM. Reason: PSA info added.


  2. #2
    Member Array vietnamvet66's Avatar
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    I have read something about this a while ago, but as far as I am concerned I will listen to my Doctor and do as he advises. My brother in law missed his yearly check about 5 or 6 years ago. After about 6 months later he finaly got to his doctor and the test came back positive, number around 8.
    After being checked by a specialist, he was treated for cancer and the first doctors told him he had 6 months to a year to live. he saught a second opinion, and went to a cancer center where the did treatments and then surgery, followed by more teatments. He is still cancer free today. without this test he would not have lived.
    I will only take my medical advise from MY Doctor, not something written by ????.
    Just my $ .02 , your mileage may vary.
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  3. #3
    Senior Member Array DoctorBob's Avatar
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    The idea is to make an informed decision knowing both the potential benefits and the potential harms of a treatment or a test. Obviously one set of his doctors got it wrong. This is why you should have an informed discussion BEFORE taking action. A lot of people have had unecessary treatment and some have missed necessary treatment. It pays to know all you can before making a decision.

    Rather than simply accept or reject what I've written, google the studies and read them for your self.

    you would be wise to NOT believe anything I post without checking the sources and reading the data in the studies for your self. The same goes with what your doctor tells you. While s/he may have your best interests at heart, it is also important that s/he keeps up with the latest data and does NOT have a financial or other interest in recommending a specific treatment.

    Go to the Jounal Of The American Medical Assoc (JAMA), June 8, 2011, volume 305, No. 22, page 2273 and read it for yourself.
    Last edited by DoctorBob; June 19th, 2011 at 12:07 PM.

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    VIP Member Array glockman10mm's Avatar
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    I have heard about this too. A radio personality, Clark Howard, was diagnosed with it and has opted for observed management instead of surgery. Also many other countries are ahead of us on this. Apparently since prostate cancer is a very slow cancer, it may be more beneficialy to not operate in most cases.
    Ignorance is a long way from stupid, but left unchecked, can get there real fast.

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    Member Array JohnInFla's Avatar
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    The Centers for Medicare and Medicaid Services (CMS) recommended coverage for treatment with sipuleucel-T for patients with terminal proastate cancere. It extends survival by about 4 months (+/- a month) at the cost of $93,000.
    It's going to be VERY hard to prevent hyper inflation of medical care costs in a setting that utilizes such expensive medication for such a small benefit...
    A very good example of the problems that arise when "who benefits" is split off from "who pays".

    If I can get you to pay for my "goodies", I'm going to take all the "goodies" I can get ... it's human nature.

    If I have to pay for my own "goodies" I may be more judicious in which goodies I buy. In the above example, if I'm informed that the treatment available will extend my life by 3 or 4 months but the cost will reduce my wife's retirement nest egg by $93,000, I may forego buying that treatment. It's my life, my/our money, my/our decision, and that's as it should be. But, for me, through the police power of government, to force you to pay the $93,000 so that I can live for another 3 or 4 months? IMO, that's wrong.

    And this is just another example of why politics and religion are topics that divide us so sharply. There are forty-eleventeen other topics that all revolve around the basic question of "who benefits vs who pays", and none of them are easily resolved.

  6. #6
    Senior Member Array DoctorBob's Avatar
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    Quote Originally Posted by JohnInFla View Post
    A very good example of the problems that arise when "who benefits" is split off from "who pays".

    If I can get you to pay for my "goodies", I'm going to take all the "goodies" I can get ... it's human nature.

    If I have to pay for my own "goodies" I may be more judicious in which goodies I buy. In the above example, if I'm informed that the treatment available will extend my life by 3 or 4 months but the cost will reduce my wife's retirement nest egg by $93,000, I may forego buying that treatment. It's my life, my/our money, my/our decision, and that's as it should be. But, for me, through the police power of government, to force you to pay the $93,000 so that I can live for another 3 or 4 months? IMO, that's wrong.

    And this is just another example of why politics and religion are topics that divide us so sharply. There are forty-eleventeen other topics that all revolve around the basic question of "who benefits vs who pays", and none of them are easily resolved.
    You hit the nail on the head with that one. Lipitor advertises that it reduces the risk of heart attacks and strokes by 30%. It does; from 3% to 2%. That actual reduction of 1% means that one patient in a hundred who is treated with this $4/day drug will avoid a 'nonfatal' heart attack if he takes the medication every day for 3.3 years. Would you pay that much for a 1% chance of benefit? How about the risk of muscle and liver damage from the medication and the cost of additional testing twice a year to insure that you are not developing hepatitis, rhabdomyolysis, or kidney failure from the medication? The Latin phrase 'cui bono' (who benefits) is the thing we should all ask about medications and treatments. If your doctor can't give you a good explanation about the liklihood of harm and benefit for a specific test or treatment, you should think aobut getting another opinion. Always ask wt the NNT (number needed to treat to save one life/ make one cure) is.

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