Sometimes you see a story that is just too important to pass up--even if the comments I make here are going to get some New York politicians upset with me and possibly with the American Cancer Society.
But when you see something that defies logic and evidence, and involves millions of dollars that could be put to much better and more effective use, then I believe we have the responsibility to say something, even if it is at our peril.
The story is about New York City subsidizing "screening MRI brain scans" to detect brain cancer early as reported in yesterday's New York Times. And my opinion and that of others is that at the least New York is wasting the taxpayers' money and at worst is promoting an unethical and experimental procedure to its citizens.
Here are the basics:
The City Council of New York has been subsidizing a truck loaded with an MRI machine that goes around the city from borough to borough offering MRI scans to detect brain cancer "early" and nominally save lives.
And here is the evidence:
There are no published studies that would support the value of these scans, much less evidence that they meaningfully reduce the risk of death from brain cancer. In short--absent a well-done research program (which I believe would fail anyway as noted below) the city is throwing millions of dollars down the drain--millions of dollars which if properly spent COULD save lives through the early detection of cancers.
And the sad part is that New York has--for other cancers, such as colorectal cancer--supported such effective screening programs for those with limited access to health care. This brain tumor scanning thing is simply not one of those programs, and political pronouncements are not going to change the scientific reality that this is completely unproven and illogical.
In fact, my colleague Otis Brawley MD who is the American Cancer Society's chief medial officer and an expert on the ethical issues surrounding clinical trials (think Tuskeegee, for example), thinks that such screening should be considered experimental and that those offering such screening need to inform the patients that it is experimental. And if it is experimental, that opens up a whole set of other issues, such as whether it needs to be approved by an institutional review board for the protection of human subjects since it is an unproven medical procedure and whether people receiving these scans should sign an informed consent.
Lethal brain cancers are not common. The American Cancer Society estimates that in 2010 there were 22020 cases of brain and spinal cord (central nervous system) cancers diagnosed in the United States, and 13140 deaths. Not rare, but not common.
There are several qualifications needed to demonstrate that routine screening of people at average risk of will be effective in reducing the disability and death from a certain type of cancer. Remember, we are talking about screening literally millions of people who have no symptoms for a specific cancer, then demonstrating that when we do that screening we are able to prove--hopefully through effectively designed, randomized trials--that such screening meaningfully reduces deaths from that cancer, and that it does so at a "cost," in false positives, harms of unnecessary treatment, etc., that makes it "worth" that cost. We have evidence that colonoscopy and mammography save lives at a reasonable tradeoff in false positives and other problems (although there is obviously some dispute about which groups of women benefit most), and most recently we had an early report that CT lung scanning can indeed reduce deaths from lung cancer, but we await more data about false positives and such
But the same cannot be said of most other cancers. We do not yet have effective screening tools that reduce deaths for some cancers that are often fatal, such as pancreatic and ovarian cancer. Included in that group, as well, are brain cancers.
Having a screening test for brain cancers might be helpful if we had evidence that such a test could be done at reasonable cost, be offered to millions of people, enabled lifesaving treatment with minimal adverse effects and basically avoided disability and saved lives. There is no such evidence that screening for brain cancer works when these principles are applied. And, we must consider the harms of treatment, especially those who may have a lesion diagnosed that was not causing them difficulty, may never have caused them difficulty, and whose treatment could bring with it the risk of significant disability.
Just having a machine that can perform a function doesn't mean that using that machine will improve someone's health. We have spent decades digging ourselves into a huge hole created with just such thinking, and now we are paying the bill. Instead of paying bills, we should be paying attention to medical evidence of what works and doesn't work in medical practice. Evidence-based medicine is finally taking hold because physicians have finally discovered the folly of "what I think" vs. "what we know."
In fact, when I first heard a number of years ago about a doctor in the New York area who was offering MRIs to reduce deaths from the most aggressive forms of brain cancers, I was astonished. But it wasn't a major issue for me, other than to use the example in my talks since then to point out the difference between proven, effective cancer screening and a test where people want to believe it might work but have no proof, while spending untold amounts of money and putting patients at untold risk without proving there is real benefit.
And now the city of New York is spending precious resources on a van that apparently stands useless much of the time. And a Council leader castigates anyone who disagrees, citing mammography as an example of something that doctors "laughed at" years ago as justification for this fiasco.
It is quite different enrolling women in a controlled clinical trial (which is what happened in New York at the beginning of the mammography era in the 1960's) and having a city backed van going around town offering unproven medical studies to thousands of people who get duped with the help of their government into thinking the van is offering a proven medical service.
So what do we do?
What we don't do is assume defensive postures and continue blasting away at people who devote their lives to understanding the prevention and early detection of cancer. We don't continue to support unproven--and potentially dangerous--medical technologies with a government endorsement.
And if we want to do some good, we figure out how to redirect that money into more appropriate medical uses, such as screening for cancers where we know early detection really does work. In this case, screening MRIs to detect brain cancer "early" simply isn't one of those cancers.
So, I plea with New York to spend the money where it is needed for things that work, whether it is food, shelter, parks or proven cancer screening. Just don't waste money on something that doesn't stand a reasonable test of medical effectiveness. It simply doesn't make you look good--or responsible as stewards of the public purse or the public's safety. And if someone is injured as a result of this unproven screening, it could prove very costly as well.