I never envisioned our life together to be possibly shortened. We were looking at cruising off into the sunset and we’re still actively raising children! And here you are and you have this diagnosis, and it’s just hard to do.
John’s tearful, anxious wife speaks these words to him as she stands beside his gurney at UCLA Medical Center in Roger Weisberg’s new documentary film, Money and Medicine. (It premieres on PBS this Tuesday, September 25.) John appears healthy and fit at 55, but a recent routine screening test detected an elevated level of prostate specific antigen (PSA), and a biopsy confirmed prostate cancer. Of several treatment choices, he elected the most aggressive option. Now he wears a surgical cap and is waiting to be wheeled into surgery, where his prostate will be surgically removed.
John understands the risks—the surgery may leave him impotent, incontinent, or both—but he considers himself fortunate. “If I had to have a tumor of this sort,” he says, “this is a much easier one to find at an early stage, and to be able to take aggressive action against it.”
I’ve blogged about cancer before, after someone close to me—I called her Bonnie—was diagnosed with breast cancer. That first diagnosis scared the hell out of Bonnie (and me). Cancer is cast as a frightening demon in our society, the focus of our collective paranoia. We think of it as a death sentence, and our impulse is to unleash the heavy medical artillery in an attempt to eradicate every last cancer cell from our body. John’s treatment decision is easy to understand.
But it’s based on a false assumption. Not all cancers will kill you. Your immune system may take care of it on its own, based on evidence that some breast, testicular, and other tumors, left untreated, regress or disappear. Other tumors—especially prostate cancer—seem content to hang around without spreading significantly for years or decades. Most elderly men die with prostate cancer—it’s found in their autopsies—but it wasn’t the cancer that killed them.
That’s why there’s such controversy over mammography and PSA tests lately. An elevated PSA test puts men on a track for invasive testing and risky treatment that may not help them at all. According to the physicians in the film, there’s no way to predict which cancers will spread aggressively and which will sit there harmlessly. “You have to remove about fifteen prostates to prevent one prostate cancer death,” says Dr. Michael Barry of the Foundation for Informed Decision Making. “The problem is, at the individual level, all fifteen of those men will think it was them whose life was saved. One of them is right, fourteen are wrong—but we don’t know which one.”
Ten months after the surgery, John defends his decision. “I believe that I may be one of the people whose life was saved, or at least extended, by going in aggressively,” he says. “Going into the surgery, I was aware of potential side effects—that I might be giving up some things that I would rather not give up. As it’s turned out, I did give up something. And I might be one of the fourteen for whom this wasn’t particularly lifesaving or in any way important. But prostate cancer kills people, and I would do it again.”
In John’s view, impotency or incontinence was a price he was willing to pay to eradicate the cancer. But there is an alternative to aggressive treatment, called “watchful waiting,” in which patients undergo no treatment but are regularly monitored, via blood tests and biopsies, to detect any spread of the cancer. The film shows another prostate cancer patient, at Intermountain Medical Center in Salt Lake City, reviewing treatment options with members of an interdisciplinary team of specialists. Once he’s informed about the real risks and probabilities of both disease and treatment, he happily chooses watchful waiting. But currently, only 10% of prostate cancer patients choose this option.
The value of watchful waiting was validated recently—too recently to affect John’s surgery decision—in the prestigious New England Journal of Medicine. Early-stage prostate cancer patients who were randomly assigned to a watchful waiting regime were equally likely to survive through the 15 years of the study as men assigned to surgery. Some men who did nothing died, as did some men who had surgery. But there was no statistical difference between the two groups.
In my earlier essay, I argued fiercely that Bonnie should be able to make her own treatment decision, based on an informed evaluation of what was right for her. John deserves the same respect, and neither filmmaker Weisberg nor I would presume to tell him that his surgery didn’t save his life. But the statistical probability is that it didn’t.
Instead, Weisberg’s film makes a larger point. Our whole health care system is geared toward doing something rather than nothing. This results in overtesting, overtreatment, and waste.
Money and Medicine shows us overtreatment in a variety of American medical settings and contexts, from the beginning of life (where “elective induction” by Caesarian section has proliferated) to the end (where one-third of medical costs are incurred). It also surveys the 95 million imaging studies (mammograms and other X-rays, CT scans, MRIs, and more) conducted in the U.S. every year.
Weisberg is an accomplished, veteran documentarian whose films air regularly on PBS. His work has won numerous awards, including two Academy Award nominations. He knows how to let his subjects tell their own story, without getting in the way. He has addressed the health care crisis before, most recently Critical Condition in 2008. I reviewed his film on capital punishment, No Tomorrow, in this space last year. (Full disclosure: he is also a long-time family friend.)
The overarching theme of Money and Medicine is that these cases of overtreatment are not isolated or accidental. Overtesting and overtreatment are integral parts of the American medical system. Every decision, every incentive—for patient, doctor, hospital, pharmaceutical and device manufacturer, insurer, and politician—is weighted toward doing more rather than less, even if it causes harm.
Of course, overtreatment is wasteful—it consumes, by one estimate, 30% of U.S. health care spending, or $800 billion a year. But, in the words of Dr. Brent James, chief quality officer at Intermountain Health Care, “one person’s waste is nearly always another person’s income.” In fee-for-service medicine, no one gets paid unless the test is ordered, the medication is prescribed, or the procedure is performed.
There’s much more to say about overspending and overtreatment in the American health care system. But let me end now and give you a chance view the film. I’ll come back to initiate a dialogue with further comments.
Money and Medicine debuts on PBS this Tuesday, September 25, 2012; be sure to check local listings. Visit the film’s PBS website to view the trailer and download the viewer guide.
Copyright © 2012, John Unger Zussman. All rights reserved.