Tuesday, November 17, 2009

Mammograms, Zetia/Vytorin, Proscar,Folic Acid

I have received many phone calls from my patients and e-mails from readers on my bloglist about 3 different reports about medical research results: an article in the NY Times by Gina Kolata(Proscar), a report from a cardiac conference(Zetia/Vytorin), and recommendations from a medical study group (mammograms). I received no inquiries about an article in Lancet (folic acid), but I guess few people read British medical journals, even though Lancet antedates both NEJM and JAMA, and their letters to the editor are invaluable. My comments on these are probably applicable to many reports of medical results, and I leave it to my readers to evaluate any such reports.

First, some general comments. In many areas of non-precise science (I am therefore excluding mathematics, chemistry and physics) when recommendations are made, there is both a majority report/recommendation, and a minority report. However, in medicine, except as a rebuttal to a journal article (e.g. the discussion in Lancet as to whether or not reducing total salt in the diet saves lives) we never see the minority report. I doubt that 20 doctors (or 20 anyones) ever agree 100% on a committee report, and it would be nice to see the minority report (cf. the arguments about global warming) so we can try to make our own decision. Furthermore, most refereed journal articles require the authors to make the source data available on request, but this does not happen with medical committee recommendations, so we have no way to judge how they arrived at their recommendations, or what compromises were made (e.g. how did the government first decide that total cholesterol levels should be below 240?). Was it the same way that Congress decided on 27.5% as the oil depletion allowance, i.e. a compromise?

The recent recommendations on the starting age and frequency of mammograms are a case in point. There was no minority report, and the data on which the recommendations were made are not available. I only fear that HMO's will seize on this report to pay for fewer mammograms, as Medicare once did. I have never had a problem with ordering a test for a patient even if I was absolutely certain the result would be negative, because the patient's peace of mind is important to me.
There is absolutely no way to know for a given individual how often a mammogram should be done (why not every 6 months to detect fast-growing cancers?), or at what age the mammograms should start. I also have some 90 year old women who have never had a mammogram, and have never had breast cancer, and so far they are right as well.

The article about men not taking Proscar even though men on Proscar have a lower incidence of prostate cancer did not properly emphasize the fact that if prostate cancer does occur when a man is taking Proscar it is much more aggressive, and has a higher Gleason score. On the other hand, taking both Proscar and Flomax decreases a man's probability of needing a TURP of the prostate to relieve blockage caused by a growing prostate. Also, some men do not like taking Proscar because it diminishes the amount of fluid in the ejaculate by at least 50%, and these men do not enjoy the different sensation, because their orgasms are therefore shorter. Why not just say that men who do not take Proscar are "pharmacologically autonomous"?

Both Zetia and Vytorin decrease cholesterol, which is all the FDA required them to do. Studies on other statins as well as on Niacin showed that lowering cholesterol by these chemicals reduced the risk of second heart attacks and strokes, as well as the risk of first heart attacks. (I have never seen a study on diet, lower cholesterol, and heart attacks.) The FDA then assumed that any chemical lowering of cholesterol was beneficial, as does the entire medical establishment.
The study of Zetia/Vytorin showed that they did not cause regression of the narrowing of the intima of a major artery. However, this is a secondary surrogate marker for strokes and heart attacks. If heart attacks are caused by rupture of plaque (as many cardiologists believe) then stabilizing the plaque (are statins anti-inflammatory as aspirin is?) is more important than the lumen diameter, after a certain narrowing. No one has shown that lowering the cholesterol with Zetia or Vytorin does NOT reduce the risk of heart attack or stroke, just as no one has shown that intimal regression is a valid surrogate for MI's and CVA's.

The latest issue of Lancet reported a large study that showed that fortifying the diet with folic acid, which successfully lowered neural tube defects in infants, INCREASED the risk of cancer. I wonder what the USA and FDA will do with this study. It certainly should be repeated. But studies showing that vitamin ingestion can cause problems rarely make headlines in America. Maybe we should revise the recent recommendations which raised the RDA for folate from 0.4mg to 0.8mg?

Thought for the month: Why does the full moon appear larger when it rises in the East than it does when it is directly overhead?

Monday, November 16, 2009

Universal Health Care: What it Should Contain

Many patients and friends have asked me during the past months what I would like to see in universal health care. I only want a system that is best for my patients, and takes the least paperwork time for me. Any system, of course, will always pay less for thinking than for doing (i.e. operating) because it is difficult to measure thinking. I defer the question of outcome measurements to another blog.

1) We already have socialized medicine, and it is called Medicare and the VA Hospitals, and none of the users of the systems seems very much dissatisfied with it. And, in fact, middle-class parents paying to put their children thru college, etc., would find it difficult if not impossible to provide dollar for medical dollar coverage for their elderly parents, as they would have to do without Medicare.

2) You are allowed (by law) to keep your same cell phone number for life, if you want to, and don't have to change it every time you switch carriers. But when you are transferred from HMO A to HMO B because your company got a better premium deal from the second company,you suddenly have to scurry around and find a new internist, gynecologist, pediatrician, and any other specialist you are seeing. This is manifestly unfair, inefficient, and disrupts the smooth flow of medical care-taking. It's one thing if a patient chooses to leave a doctor, but to be forced to leave a doctor is unconscionable and stressful. And what if you are a Cigna patient but the world's expert is an Oxford surgeon? Then you have to pay his full bill, with no insurance deduction. You should be able to KEEP THE SAME FAMILY DOCTOR FOR LIFE!

3) Many patients are tied to their jobs thru their health insurance. If they stop working or switch their jobs, their wife and children may not be covered, or there may be very special coverage available only while they work for this particular company.

4) A minor point: why does the family coverage for your children stop when they are 23 years old?

4) A stronger point: If you and your wife both have paid premiums for a $100K fire policy on your house, and it burns down, you both get paid $100K., because you each have a policy. But if you and you wife both have paid medical premiums for a family policy, and you get a heart attack,you can only collect doctor and hospital bills from one of your policies. This means the other one was invalidated for this case, and all the premiums (10, 20 30 years' worth)are sheer profit for the company. Why should this be? It's like reverse double-dipping,only this time your pockets are the ones being directly dipped into.

5) I should not have to waste my time calling up for permission for MRI's. I don't have to do it for MCR, but most HMO's want me to expose a patient to cancer-causing Xrays of a CT exam before they allow an MRI, or I have to spend a lot of time (my least fungible recourse) convincing them otherwise.

6) I could also save time if I didn't have to call the drug management company to explain why the drug I chose for my patient is preferable to their chosen (and cheaper) drug. They don't know the patients. (Actually, must drug stores and wholesalers make a greater per cent profit on generics than brand names, because no one outside the field knows how cheap it is to make a generic.)

7) They should not make Electronic Medical Records mandatory until they have proved that they save money, or at least patient morbidity. There has been no clear evidence of this yet.All I know is that in the "good old days" I could admit a patient and write a set of orders with pen and paper in 5 minutes. Now with filling out the matrix in the computer form in the sequence of questions they ask me (e.g. what is my patient's flu vaccine status, a fact I always put down in my admitting note) punching in my date of birth xx-xx-xxxx (not a code) just more information collected, so all doctors tend to be born on 11-11-1911) it takes me at least 25 minutes to admit a patient. This is not progress, but more on the EMR on another blog.Sometimes when I get tired of all the pettifogging, if it is my personal patient, I just put down patient refuses".

In summary: keep the same doctor for life, and also solve the problem of who will pay for abortions, because as long as we have both men and women, married or unmarried, we will have unwanted pregnancies,