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Common-Sense Medicine
Will medical studies of dubious validity decide whether you get life-saving treatment?


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Marc Siegel

For lung experts everywhere, there has never been much controversy about smoking and lung cancer. If patients stop smoking, their risk of lung cancer drops dramatically. If they don’t, our best chance to save them is to detect the cancer early; one study shows a 60 percent chance of a surgical cure when lung cancer is found at an early stage.

The best test we have to screen smokers is the spiral CT scan. This uses computer-generated images to examine the lungs from different angles; studies have long shown that a chest x-ray alone is ineffective. But in the spirit of regulatory medical practice, a controversy has existed about whether scanning the lung actually prolongs life. Back in 2007, two studies, one published in the New England Journal of Medicine and the other in the Journal of the American Medical Association, came to opposite conclusions on this question.

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Between 2007 and now, pulmonologists have continued to order the test, while insurance companies have continued not to pay for it, pointing to its expense and the inconclusive evidence that it actually saves lives.

The absurd controversy over this test was a harbinger of what is to come under Obamacare. Page 1,617 of the Obamacare bill puts aside $500 million or more per year for “comparative effectiveness” research, i.e., questionable studies intended to show that one test or treatment is better than another. Never mind that these studies can easily be misinterpreted, leading to claims that a life-saving test is not useful; under Obamacare, they will be used to decide what the government will and will not pay for.

To end the controversy over spiral CT scan, a study was conducted by the National Cancer Institute (at a cost of $250 million, funded by taxpayers). More than 50,000 smokers and former smokers were followed for eight years; one group was screened with chest x-ray, the other with spiral CT scan. The preliminary results have now become available, and they show that the CT scan reduced lung-cancer deaths by 20 percent and deaths from other causes by 7 percent. In other words, the study came to the same conclusions that most doctors (and patients) had already come to on their own.

In the brave new world of Obamacare, I fear that there will be too much focus on using insufficient evidence to try to deny essential tests. Medicine is an art when it is practiced properly; I need the best tools possible to treat and cure difficult cases. Lung cancer is certainly no exception. With more than 200,000 new cases every year and more than 150,000 deaths (less than a 15 percent five-year survival rate — it’s the number-one cause of cancer death), it is crucial to discover a tumor as soon as possible, before it escapes the lung.

So how will the absurdly expensive NCI study affect the comparative-effectiveness tribunals of Obamacare? Will the Independent Medicare Advisory Board (when it gets started in 2014) continue to deny this screening test based on the claim that in the wrong doctor’s hands it leads to too many biopsies and surgeries? Or will this latest study (known as the National Lung Screening Trial) lead Medicare and other insurance providers to pay for it? At a time of economic struggle, did we really need $250 million in taxpayer money to pay for what we already knew?

As the Obamacare insurance blanket stretches to cover millions more people, more and more either/or choices will be made. If this useful, expensive screening test for smokers is now covered as a result of this study, which useful MRI or PET scan will be denied as a result?

— Marc Siegel, M.D., is an associate professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center. He is a Fox News medical contributor.



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