Critical Condition

When Preventive Medicine Kills

The health-care bill currently being considered by Congress comes with a hefty price tag. The Congressional Budget Office pegs the cost of Obamacare at $1 trillion. President Obama has largely shrugged off these criticisms, touting amorphous “savings” such as preventive medicine.

At first blush, prevention seems great. Preventing and detecting disease early to save lives and money — sign me up. But, as new research in this week’s Journal of the National Cancer Institute highlights, prevention unfortunately is not as simple as President Obama would like to depict. Two Dartmouth physicians studied prostate cancer diagnosis-and-treatment statistics, starting with the introduction of prostate-specific antigen (PSA) screening. PSA is a screening technique used to detect prostate cancer early; it is of questionable value. The American Cancer Society recommends physicians offer patients the test at age 50, accompanied by an explanation of its risks and benefits.

PSA can help doctors detect prostate cancer early in its course. For a substantial number of those patients diagnosed by the PSA test, however, the cancer never would have attained clinical significance, which is to say it would not result in symptoms, much less death. But doctors have no way of telling who will develop problems, so everyone is confronted with critical decisions on treatment regardless of benefit. The authors used 1986, the year before the introduction of PSA, as a benchmark and concluded that, since then, an additional 1,305,600 men have been diagnosed with prostate cancer, of whom 1,004,800 have been treated for the disease. This increase in diagnosis and treatment after 1986 has been most striking in men less than 50 years of age.

Because of a preventative measure, PSA, many of these patients were over-diagnosed and over-treated. They were treated unnecessarily for symptoms they did not have and never would have had. Even when employing the most optimistic benefit assumptions, “the vast majority of these additional 1 million men did not benefit from early detection,” the report concluded. While the benefits may have been scarce, the potential adverse consequences from unnecessary prostate-cancer treatment, consisting of surgery and radiation, are severe. Side effects from these unneeded treatments range from impotence to death, not to mention that these unnecessary interventions also cost money and impose an intense psychological toll on both patients and loved ones.

This is not to say that preventive measures are necessarily harmful on balance. For example, exercise and nutrition are effective methods for maintaining good health. But most forms of preventive medicine are a little more complicated than “an apple a day,” and financial benefits are by no means obvious or inarguable. Preventive medicine will certainly not result in anywhere near $1 trillion in savings to offset the bill for Obamacare. It may, in fact, produce no net savings: As new patients needlessly clog the system — and costs soar while anticipated “savings” fail to materialize — the consequences could be disastrous.

President Obama is quite calculating. Clearly he can’t be betting the farm on something as vague and unproven as preventive medicine to finance reform efforts. I bet he has an ace up his sleeve. I wonder what it could be? Perhaps, just perhaps, he plans on asking the British National Health Service for advice.

– Jason D. Fodeman, MD, is a recent graduate of Albert Einstein College of Medicine.