Mammograms are in fact fuzzy things. Reading them accurately is a challenging task—much more challenging than even many medical professionals realize. As Timothy J. Jorgensen has noted, when 160 gynecologists were asked to assess the likelihood of a fifty-year-old woman having breast cancer if her mammogram was positive, 60 percent of them thought the chances were 8 or 9 out of 10. “The truth is that the odds the woman actually has cancer are only 1 in 10,” writes Jorgensen. Remarkably, radiologists do little better.
The unfortunate bottom line is that breast cancer screening doesn’t save a lot of lives. For every thousand women screened, four will die of breast cancer anyway (either because the cancer was missed or because it was too aggressive to be treated successfully). For every thousand women who are not screened, five will die of breast cancer. So screening saves one life in every thousand.
Men face similarly unhappy prospects with prostate screening. The prostate is a small gland, about the size of a walnut and weighing just one ounce, which is chiefly involved in producing and distributing seminal fluid. It is tucked neatly—not to say inaccessibly—up against the bladder and wrapped around the urethra like a neckerchief ring. Prostate cancer is the second leading cause of cancer death among men (after lung cancer) and grows more common as men get to their fifties and beyond. The problem is that the test for prostate cancer, called a PSA test, is not trustworthy. It measures levels in the blood of a chemical called prostate-specific antigen (PSA). A high PSA reading indicates a possibility of cancer, but only a possibility. The only way of confirming if cancer exists is with a biopsy, which involves sticking a long needle into the prostate via the rectum and withdrawing multiple tissue samples—not a procedure any man is likely to undertake eagerly. Because the needle can only be randomly inserted into the prostate, it is a matter of luck whether it strikes a tumor or not. If it does find a tumor, there is no telling with current technology if the cancer is aggressive or benign. On the basis of this uncertain information, a decision must be made on whether to surgically remove the prostate—a tricky operation with frequently dispiriting consequences—or treat it with radiation. Between 20 and 70 percent of men suffer impotence or incontinence after treatments. One in five experience complications from the biopsy alone.
The PSA test is “hardly more effective than a coin toss,” Professor Richard J. Ablin of the University of Arizona has written, and he should know. He was the man who discovered the prostate-specific antigen in 1970. Noting that American men spend at least $3 billion a year on prostate tests, he added, “I never dreamed that my discovery four decades ago would lead to such a profit-driven disaster.”
A meta-analysis of six randomized control trials involving 382,000 men found that for every 1,000 men screened for prostate cancer, about one life was saved—great news for that individual, but not so good for the large numbers of others who may spend the rest of their lives incontinent or impotent, the majority of them having undergone serious but possibly ineffectual treatments.
All this isn’t to say that men should absolutely avoid PSA tests or women breast cancer screening. For all their flaws, they are the best tools available, and they do indubitably save lives. But those undergoing screenings should perhaps be made more aware of the shortcomings. As with any serious medical issue, if you have concerns you should consult a trusted physician.
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Accidental discoveries made during routine investigations happen so often that doctors have a word for them: “incidentalomas.” The National Academy of Medicine in the United States has estimated that $765 billion a year—a quarter of all health-care spending—is wasted on pointless precautionary maneuvers. A similar study in Washington State put the amount of waste even higher, at nearly 50 percent, and concluded that as much as 85 percent of preoperative lab tests are completely unnecessary.
The problem of overtreatment is exacerbated in many places by fear of litigation and, it must be said, by a desire of some doctors to inflate their earnings. According to the author and physician Jerome Groopman, most doctors are “less concerned about healing and more worried about being sued or maximizing their income.” Or as another commentator put it more drolly, “One person’s overtreatment is another’s income stream.”
The pharmaceutical industry has a lot to answer for in this respect. Drug companies commonly offer generous rewards to doctors to promote their drugs. Marcia Angell of the Harvard Medical School, writing in The New York Review of Books, has said that “most doctors take money or gifts from drug companies in one way or another.” Some companies pay for doctors to attend conferences at luxury resorts where they do little more than play golf and enjoy themselves. Others pay doctors to put their names to papers that they haven’t in fact written or reward them for “research” that they didn’t really do. Altogether, Angell has estimated, drug companies in America spend “tens of billions” of dollars on direct and indirect payments to doctors every year.
We have reached the decidedly bizarre point in health care in which pharmaceutical companies are producing drugs that do exactly what they are designed to do but without necessarily doing any good. A case in point is the drug atenolol, a beta-blocker designed to lower blood pressure, which has been widely prescribed since 1976. A study in 2004, involving a total of twenty-four thousand patients, found that atenolol did indeed reduce blood pressure but did not reduce heart attacks or fatalities compared with giving no treatment at all. People on atenolol expired at the same rate as everyone else, but, as one observer put it, “they just had better blood-pressure numbers when they died.”
Drug companies have not always behaved in the most ethical of ways. Purdue Pharma paid $600 million in fines and penalties in 2007 for marketing the opioid OxyContin with fraudulent claims. Merck paid $950 million in fines for failing to disclose problems with its anti-inflammatory drug Vioxx, which was withdrawn from sale, but not before it had caused perhaps as many as 140,000 avoidable heart attacks. GlaxoSmithKline currently owns the record for a penalty—$3 billion for a raft of transgressions. But to quote Marcia Angell again, “These kinds of fines are just the cost of doing business.” For the most part, they come nowhere near offsetting the huge profits made by the errant companies before they are hauled into court.
Even in the best and most diligent circumstances, drug development is an inherently hit-or-miss undertaking. Laws almost everywhere require researchers to test drugs on animals before they try them out on humans, but animals don’t necessarily make good surrogates. They have different metabolisms, respond differently to stimuli, contract different diseases. As a tuberculosis researcher observed years ago, “Mice don’t cough.” The point was frustratingly well illustrated on tests of drugs to fight Alzheimer’s. Because mice don’t get Alzheimer’s naturally, they must be genetically engineered to accumulate in their brains a specific protein, beta-amyloid, associated with Alzheimer’s in humans. When such doctored mice were treated with a class of drugs called BACE inhibitors, their beta-amyloid accumulations melted away, much to the excitement of researchers. But when the same drugs were tried on humans, they actually worsened the dementia in test subjects. In late 2018, three companies announced they were abandoning clinical trials of BACE inhibitors.