As physicians and patients join in the metaphoric burning of managed care in effigy, the obvious question persists: who’s minding the store?
The question occurred one Sunday evening in May during a report on 60 Minutes in which two prostate cancer patients and a urologist discussed the disease, the treatment alternatives, the consequences, and the suggestion that the best treatment could be no treatment at all. A companion report did the same for ductile carcinoma in situ (DCIS) patients and its treatment alternatives. The segment raised the possibility that we may be overtreating some cancers, which echoes what I have been hearing for some time in the grumblings of mammographers on the overtreatment both locally and systemically of DCIS.
In “The Flip Side of Malpractice” (page 34), associate editor Chris Wolski quotes Leonard Berlin, MD, on the subject: “The trouble with ductile carcinoma in situ is that most never develop into invasive cancer (nobody knows the exact figures), most will never grow, most will never injure or kill a woman. Some do, but it’s probably no greater than 25%.” The placement of this story within a broader story on malpractice and mammography raises an irony that will not be lost on radiologists: they are not sued for finding cancers, however threatening or not. They are sued for not finding them. Yet the overtreatment of nonthreatening cancers represents a squandering of resources that will become even more precious as the proverbial monkey in the python-otherwise known as the Baby Boom generation-works its way through its years of greatest consumption of health care services.
As key players in disease triage, radiologists are intimately connected with this issue of overtreatment, particularly as the technological tools they wield become increasingly refined, at both the anatomical and the molecular levels. This point was underscored during a recent public forum in Cleveland on whole-body scanning, jointly sponsored by the Cleveland Clinic and the Society for Computer Applications in Radiology. Abdominal imager Brian Herts, MD, regaled the audience with comparison 3-D reconstructions of a coffee pot that had been imaged by 4-slice and 16-slice multidetector CTs, not to mention a series of remarkable 3-D images of the vessels of the heart. In presenting both the pros and cons of the highly charged whole-body scanning debate, Michael Modic, MD, chairman of radiology at the Cleveland Clinic, suggested that a key driver for the practice is the enhanced ability to find diseases during their detectable preclinical phase, providing researchers with the requisite information to develop what he called the “natural history of a disease.” This brings us full circle to the original question: what is to be done with the disease after it is found?
There is, it seems, an opportunity for radiologists to collaborate with their brethren in oncology as well as other specialties, to develop the clinical research, particularly in the realm of cancer, that would finally produce the outcomes that have long eluded radiology’s attempts to gather them. Evidence-based medicine is a viable, even necessary, alternative to managed care.