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At Health Journalism 2012 in April, keynote speaker Otis Brawley, M.D., the American Cancer Society’s chief medical and scientific officer, spoke eloquently about how the health system doesn’t provide incentives for the best care and specifically addressed screenings.
Frederik Joelving
The risks and benefits – both physical and fiscal – of cancer screening have become a burning topic, and have been absorbed into the endless political controversies surrounding the Health Policy law. Are certain tests “essential benefits” or a boondoggle that can actually do more harm than good? And if they are deemed “unessential,” then someone who disagrees inevitably uses the R word (rationing.) We asked Reuters Health reporter Frederik Joelving to share how he reported on a high-profile doctor touting a new screening test. The test may be quicker and cheaper than the standard procedure, but hasn’t been proven to help anyone.
By Frederik Joelving
Like most journalists, I get dozens of boilerplate press releases and email pitches every day. Those that aren’t caught by my spam filter usually get the one-click treatment. But a few months back, an email from a large ear, nose and throat practice caught my attention. It talked about a “devastating disease,” a “remarkable direct-to-consumer advertising campaign” involving a renowned medical center and a two-minute screening procedure that “is going to improve survival from esophageal cancer through early detection.”
That’s three red flags for anybody who’s been following the fierce debate over screening. While the idea of catching disease early sounds intuitively compelling, the prostate cancer story shows even the simplest of tests can have a big price tag when it becomes routine – and I’m not just talking finances.
So I decided to dig a little and called a source at the U.S. Preventive Services Task Force, a great resource of unbiased information on preventive medicine.
As it turned out, the task force hadn’t looked at the evidence for esophageal cancer screening. If it had, it would have found very little. As I talked to more experts and read through guidelines from medical specialty groups, it quickly became clear that no one had ever done a clinical trial to see if screening for esophageal cancer saves lives.
Yet the practice that pitched me, called ENT and Allergy Associates, is calling for routine screening for the disease. Thanks to a new procedure called transnasal esophagoscopy, or TNE, the test is now a cinch, I was told.
During TNE, a thin flexible tube tipped with a camera is passed through the nose into the esophagus, where the doctor can then take a small biopsy. By going through the nose instead of the mouth – the traditional route – TNE bypasses the gag reflex. That avoids the need for sedation and makes the screening test cheaper and faster than it used to be.
The main driving force behind the new campaign, Dr. Jonathan Aviv, said he believes he has saved a life every time he finds precancerous cells in a patient’s gullet.
“The disease is devastating … and it’s very easy to stop,” Aviv told Reuters. “Everyone over 50, just like they have a screening colonoscopy, should have a screening esophagoscopy.”
When I pressed him, Aviv acknowledged that he owns several thousand shares in the company whose technology (the tiny camera that goes through the nose and down the esophagus) he is touting. He also has been a paid consultant to other companies that make or sell related equipment. Each time he screens a patient, his practice makes a few hundred dollars.
Because there aren’t any clinical trials of esophageal cancer screening, it’s hard to know how the potential risks and benefits break down. But through interviews with experts, I learned that the procedure can cause nose bleeds and false alarms. And once you’re diagnosed with precancerous cells – a symptomless condition called Barrett’s esophagus that affects millions of Americans – you will be advised to get re-tested every few years for the rest of your life.
To understand what it’s like to live with a Barrett’s diagnosis, I contacted a few patient support groups (the Association of Gastrointestinal Motility Disorders was particularly helpful). The people I talked to all told me pretty much the same story: It’s like having a ticking bomb in your throat. That’s why some choose to have expensive preemptive treatments, such as burning off the lining of the esophagus.
But according to the latest research, it’s very unlikely that Barrett’s esophagus will ever turn into cancer – the annual risk is only around one in 1,000. Every year in the United States, about 10,500 people get esophageal adenocarcinoma – the tumor Aviv is screening for – which means the disease is still fairly uncommon among cancers.
(Despite this, one 2005 study found many insurance companies refused to provide health insurance to people with a new Barrett’s diagnosis and hiked life insurance premiums two to three times.)
While esophageal cancer screening isn’t routine at this point, to me the new campaign looked very much like a blueprint for the next prostate cancer debacle. Without any good data, and with massive conflicts of interest, doctors are pushing a new technology that may or may not save lives, but is certain to inflate the nation’s health bill and cause harm to some people.
That information deserves to be in the public domain before consumers are hit with ENT and Allergy Associates’ “remarkable direct-to-consumer advertising campaign.” So I’m glad I read their pitch, although by now they probably wish they hadn’t sent it.
Frederik Joelving is a reporter and editor with Reuters Health.
