Every year the American Cancer Society releases an update to our guidelines for the prevention and early detection of cancer in our journal CA: A Cancer Journal for Clinicians, and this year is no different.
As far as our guidelines are concerned, there are no new or revised guidelines this year.
But there are some interesting bits of information in the text of the article that bear emphasis, if for no other reason than they provide a “state of the nation” on where we are with respect to how well we are doing getting folks screened for cancer.
When you look at the data as to how many people are getting screened for cancer, you can see that we do a pretty good job of screening women for cervical cancer, and not so good for colorectal cancer. You can also see that for some cancers, in particular breast cancer, the screening rates have actually decreased a bit for reasons that are not clear.
My colleagues who are the experts in this area tell me they aren’t certain if this is a leveling off for mammography, or reflects an actual trend downwards. Either situation, however, is not good.
Mammography as a service is under pressure. There are some quality issues that have been raised, and fewer radiologists are becoming specialists in mammography. There are fewer sites available around the country where a woman can get a mammogram. Women may be coming complacent about getting screened every 12 months.
All of these are important, but there may be more significant issues at play as well.
As noted in the article, there are two paramount conditions that increase screening for cancer. One is having a doctor or health care provider say that getting screened for cancer is something that is important for your health. This goes hand-in-hand with having a “medical home,” that is a doctor, a clinic or a practice that you can identify as your regular source of medical care.
The other condition is having health insurance. As shown in the tables in the articles, people without health insurance have a very low rate of screening.
And, although there are federal programs to provide mammograms and cervical cancer screening to underserved women, there aren’t enough funds to provide this service to every eligible woman in this country.
There may be some other more subtle factors at work here as well.
For example, I suspect many of my primary care doctor colleagues (for whom I have great respect and admiration) have “prevention fatigue.” They forget how important their recommendation is to their patients. So, they either don’t make the recommendation to get screened, or if they do, they don’t put the “oomph” behind it that would send the signal to the patient that this is something they need to do.
Another reason is that much of our health care in this country is episodic and opportunistic. That means you go see the doctor when you have a problem, but don’t go when you don’t.
The annual physical that was so much a part of my practice and my medical upbringing back in the 1970’s has been basically put out of business for many folks. There are many reasons for that, but the bottom line is that when you see the primary care doc these days you probably have a problem, have 7-10 minutes to review that problem, and then may or may not see them again depending on what the problem is.
There really is no time—and no payment—for the doctor to talk to you about preventive health care.
That leads me to another thought: we live in a health care environment that emphasizes illness, not health and prevention. Our entire system for the most part is geared to getting you well, not keeping you there in the first place.
Wellness is a frustrating business for the doctor. I know, because I have “been there, done that.” I hate to say this, but as a doctor you don’t do well (financially) by keeping people well (unless you own one of those high end prevention clinics). The more illness you treat, the more surgery you perform, the more x-rays you do, the better off you are.
I started off my professional career as a full time medical oncologist. For several reasons, I shifted over into primary care internal medicine after a little over a decade as an oncologist.
One of the reasons I changed my practice was that I wanted to carry the message of health to my patients. Don’t smoke, eat right, keep off the weight—you are probably familiar with the drill. I believed in treating hypertension first with a diet (which would work for most folks if they could stick to it). Ditto for early diabetes and elevated cholesterol.
So how did it work? Let’s just say that despite my best efforts and patients that were hard working, committed people, there were only a handful that could sustain a genuine long term commitment to losing weight and altering their diet.
I had a bit better luck convincing people to get screened for cancer, based on the knowledge and recommendations that were known at that time.
If we fast forward to today, my suspicion is that patients are better informed, but there are so many other things “on their plates”, so to speak, that getting screened just doesn’t rise to the top of their “to do” list. It is difficult to take the time, pay the money and go through the process of getting screened for several cancers where recommendations exist.
And then there are the recommendations themselves. They are not easy to understand for many people and many doctors for that matter.
I did a spot on ABC News Now with Tim Johnson yesterday (this is a subscription service, and I cannot provide a link directly to the interview). We had plenty of time to discuss the issue about screening for cancer. But when it came to saying what needed to be done for each cancer, there was no way we could provide all of the pertinent information.
I think we did a pretty good job of getting some basic information to the viewers (Dr. Tim is excellent at this). We made the point that you should consult with your doctor (I hope your doctor knows the current recommendations). We also said you could call the Cancer Society (800 ACS 2345) or go to our website at www.cancer.org for more detailed information (information on guidelines and prevention is found on another location on the website).
But, even if you do that, I doubt that many folks would be able to recall all of the information and nuances in the guidelines, let alone realize that there are special situations for certain people at higher risk for certain cancers.
Which brings me back to the central point of this discussion: We could do a much, much better job of helping people through this process. We could develop reminder systems, as suggested by the authors of the CA article noted above. We could improve data collection so we can really tell whether or not people are getting screened and monitor our progress in something close to real time (once again as suggested in the article).
What we really need is a national commitment to health that is data and information driven, backed up by public messaging and reinforced by commitments of medical professionals, their associations, the voluntary non-profit health organizations (such as the American Cancer Society), government, insurers and the business community. We need to get people screened and keep them healthy.
I suspect I am dreaming. But the enormity of the task should not be a barrier to getting started on turning around our attitudes about health.
As we age, we are vulnerable. It behooves us to understand that, and work on our health before the proverbial horse gets out of the barn. We can take charge of our lives. But it takes commitment, and these days it seems especially difficult to take on that responsibility for ourselves when so many others are making their demands and entreaties for our time and our attention.
Do yourself a favor, and take charge of your health now, before it’s too late. Whether it’s screening for cancer, losing some weight or eating right—do it now.
Prove my skepticism is misplaced, please!!!!