As a class of human beings, cardiologists do not enjoy subtlety or nuance. Indeed, the reason most of them chose to specialize in cardiology, as opposed to specializing in some other organ system, is that the heart is the most unsubtle organ in the body. Unlike, say, the liver or the kidneys or even the brain (which, after all, just sit there), the heart does something quite obvious, and furthermore it does it 50 – 100 times per minute (so that even a physician with a very short attention span is likely to notice).
So perhaps it is not surprising that cardiologists seem to have entirely failed to mark certain emerging – and quite subtle – currents in the “preventive health” movement, and accordingly, continue to unabashedly seek more and more “preventive tools,” whatever the cost, with all the sensitivity and social awareness of the cousin who obliviously shows up at the funeral of the family priest wearing a pro-choice lapel pin.
DrRich pointed out some time ago that preventive medicine – even on those novel occasions when it happens to actually prevent something – more often than not costs the healthcare system more money than it can ever save, and therefore, at some point in time would have to be stifled. DrRich thought it would be obvious to most of his readers (most of you being of above average intelligence) that the stifling of preventive medicine, when it occurred, would have to be relatively subtle, since it remains a central tenet of our healthcare reformers that “prevention” is the very engine by which we are going to rescue ourselves from fiscal oblivion. In retrospect, DrRich should have spelled all this out for cardiologists and any other unfortunates who habitually take whatever the reformers say at face value.
The relatively subtle undermining of preventive medicine, just as DrRich predicted, has begun. Just last week, the American Cancer Society “revised” its longstanding advice about screening for breast and prostate cancer. Whereas the traditional message has been that screening allows the early detection of cancer, and that early detection of cancer is always and obviously a good thing, the “new” and emerging message begins to question this conventional wisdom. According to Otis Brawley (CMO of the Cancer Society), “The advantages to screening have been exaggerated.” The Cancer Society, apparently, has made the calculation that it is time to begin educating the public that routinely screening for at least some cancers may sometimes be counterproductive. Namely, screening might detect small and relatively harmless tumors that, if undetected, might not impact one’s longevity.
Of course, this fact has been known for a very long time. (At least it has been known for prostate cancer. The idea that some early breast cancers might be better just left alone is new, controversial, and rather unsettled.) But until now, the calculus has been that pointing out the possible “downside” of some types of cancer screening might cause people to discount the benefits of screening altogether, and thus would produce more harm than good. It appears (DrRich supposes) that the high costs of cancer screening and early detection are finally beginning to overcome such reticence. (Those costs are threefold: the cost of the screening test itself; the cost of treating all that marginally-harmful “early” cancer; and the cost of treating actual, clearly malignant cancers that, if undetected, might result in a much quicker and much cheaper demise.) We have, apparently, reached the tipping point. The new calculus is that it is time to level with the public about the risks as well as the benefits of routine cancer screening for certain tumors – even if it does undermine the more general, more positive, “cleaner” message about cancer screening that we’ve spent decades and many millions of dollars to convey to the public.
Similarly, earlier this month the U.S. Preventive Services Task Force (USPSTF) quietly released a study of nine “emerging” risk factors for heart disease, and concluded that none of them are worthwhile. That is, there is no convincing evidence that routinely measuring any of these risk factors materially assists in reducing the incidence of cardiac disease.
Notably, one of these now-useless screening measures is C-reactive protein, the very marker that was used in the notorious Jupiter trial to identify a population of apparently healthy patients whose lives could be prolonged by administering Crestor (an astoundingly expensive statin drug).
Another of these now-discredited measures is the cardiac calcium score, measured by cardiac CT scanning. The calcium scan was endorsed in formal “evidence-based” guidelines promulgated by the American College of Cardiology and American Heart Association as recently as 2007. However, the USPSTF pointedly notes that it was unable to discover the evidence upon which this evidence-based guideline was advanced, despite reviewing all the references provided by these august professional organizations. (DrRich will only remark, once again, that he is in no way surprised or even dismayed that different expert groups with possibly different agendas can view the same body of scientific evidence and come to completely opposite conclusions. This suggests, of course, that when we are all living under a “Comparative Effectiveness Research” paradigm, everything will depend on who is doing the interpreting. We Americans should note carefully the membership of the FECCER, as we may live and die by their scientific analyses.)
But the point of this post is not to describe the many ways in which clinical trials or their interpretation can be subject to bias (DrRich has done that elsewhere); rather it is merely to demonstrate that the time has finally arrived for quietly establishing the means by which various types of preventive medicine can be brushed aside. Whether it’s by “re-educating” the public on some of the trade-offs in preventive testing even (at the risk of undermining clarity), or by “re-interpreting” scientific evidence that has been fully digested by respected professional organizations, pathways are being set up for stifling various types of preventive healthcare if doing so may be desirable.
DrRich notes that he is not actually disagreeing with the American Cancer Society or the USPSTF in the specifics of their recent activities; indeed, he suspects that both organizations are largely correct in those specifics. Rather, he is merely observing that it is gradually and subtly becoming politically correct – and even politically feasible – to quietly undermine one of the central tenets loudly espoused by our healthcare reformers, namely, that we have the tools to save hundreds of billions of healthcare dollars through preventive medicine. Saving money, to the contrary, will require us to abandon many of the “preventive” tools that are now in vogue, and the reformers know that. They are no doubt thankful that avenues for stifling such preventive care are being quietly established. Heck, they are most likely complicit in their establishment.
Which brings us back to the clueless cardiologists. They are clueless, of course, because they are listening to the “preventive medicine” mantra without observing what is actually going on in the field. They fail to understand that the very last thing the healthcare reformers actually want are new methods for identifying even more patients who are at increased risk for heart disease, and who will therefore require (no doubt expensive) medical intervention.
Because they are such concrete thinkers, and cannot discern what the reformers actually mean but only what they say, cardiologists continue to expend tremendous energies and huge funds devising ever-more esoteric cardiac risk factors, and the techniques to measure them. Such efforts are not only not needed, they are unwanted. (Simply walk down any street in any American city, and you will easily observe countless individuals who are very obviously heart-attacks-in-waiting. We are not suffering either from an insufficient number of high-risk individuals, or the simple means to identify them.)
As a case in point, incredibly (and sadly), cardiologists from the Wake Forest University School of Medicine recently reported in the American Journal of Clinical Nutrition that the amount of fat on the pericardial sac is a better measure of cardiac risk than either body mass index (BMI) or waist circumference. (The pericardial sac is the lubricated, fibrous “pouch” which encloses the heart. Its purpose, apparently, is to protect the lungs, blood vessels, and other vital structures from electrophysiologists who inadvertently puncture the heart while performing ablation procedures or positioning pacemaker wires, or otherwise messing around inside there.) Pericardial fat can be measured by chest CT scan or echocardiography (depending mainly on which type of equipment one has invested in).
In reviewing this study, DrRich finds it interesting that (contrary to every dogma known to man) BMI did not correlate at all with subsequent cardiac risk (and so measuring pericardial fat was literally only better than nothing); and further, pericardial fat correlated with cardiac risk only marginally better than did waist circumference. Yet, the authors seem quite encouraged that their new finding can potentially be parlayed into an important new risk stratifier, and thus may some day become a much-desired feature of the preventive medicine utopia we all are now constructing.
Even without the recent, little-noticed tendency of our betters to begin “questioning” certain screening tests, the idea of measuring pericardial fat as a viable way to assess cardiac risk can only be considered absurd. (Chest CT scans and echocardiograms are not cheap, costing several hundred dollars, and – in the case of CT scans, at least – are not devoid of risk. In contrast you can weigh yourself for a quarter, and your tailor will measure your waist circumference for free.)
More than 100 emerging cardiac risk factors – and the means to measure them – are now being enthusiastically evaluated by DrRich’s cardiology brethren, all of whom are convinced they are doing God’s work (and, it goes without saying, our healthcare reformers’). Pericardial fat is merely one of these.
DrRich finds it disturbing that his colleagues remain so concrete in their thinking, and are so completely missing the clear signals now being sent, strongly suggesting that preventive medicine ultimately may not be as warmly embraced as we are today being so passionately promised. DrRich wishes his heart-oriented colleagues all the best, but sadly, must consider their prognosis guarded.
*This blog post was originally published at The Covert Rationing Blog*