Just how difficult it is to get physicians to break the habit of unnecessary medical testing can be seen in a study released earlier this week by researchers at the U.S. Centers for Disease Control and Prevention (CDC).
The study, published online in JAMA Internal Medicine, found that less than 20 percent of primary care physicians, including ob-gyns, follow current medical guidelines for how often women should be screened for cervical cancer with a Papanicolaou (Pap) test.
“Getting physicians to do less testing and patients to accept less testing in many clinical situations is like swimming upstream,” wrote Dr. Michael L. LeFevre, a professor of family medicine at the University of Missouri, in a commentary that accompanied the study. “The forces to do more rather than less, particularly for ‘early detection’ of asymptomatic disease, are powerful.”
For more than a decade, the American Cancer Society (ACS) and other medical organizations have recommended that cervical cancer screening begin at age 21 and continue every three years until age 65. In 2012, the ACS extended that interval to every five years for women aged 30 and older who are also being tested for human papillomavirus infection (HPV), a risk factor for cervical cancer.
Pap tests are not recommended for women younger than 21, whether or not they are sexually active, nor for women over 65, unless those women’s past test results put them at high risk for developing cervical cancer.
For the study, the CDC researchers examined the results of national surveys taken of primary care physicians annually from 2006 to 2009 — after the every-three-years guidelines were established. About 500 physicians participated in the survey each year. Most were male (60 percent), 45 years or older (64 percent), and practiced in metropolitan areas (85 percent). About 26 percent were ob-gyns; the rest were general practitioners.
The physicians were provided with several hypothetical scenarios in which they were asked, “When would your practice recommend that a woman between 30 and 60 years of age return for her next Pap test?”
In all the scenarios, a majority of the physicians recommended re-screening the women sooner than called for in the guidelines. For example, in scenarios where a woman had two consecutive normal Pap tests with negative HPV results, 67 percent to 84 percent of the doctors recommended that the woman be rescreened sooner than the recommended three years.
LeFevre notes that there are several explanations — some commendable, some not — for these troubling findings.
“First, the noble ambition of physicians is to do good,” he writes. “Unfortunately, this ambition is too often accompanied by either the failure to recognize or the ability to ignore harm. A ‘don’t just stand there, do something’ approach is supported by what appears to be a strong cultural belief within the public that medical care can only do good, not harm, and that more care is always better than less.”
Liability concerns are also a factor, he adds, as are “disease advocacy organizations [that] commonly promote more testing in general and screening and early detection specifically. Little attention is paid to the science needed to inform us of either the benefits or harms of such early detection. So often the mantra, is, ‘if we can save even 1 life, it is worth it.’ “
Then there are the financial rewards.
“The existing payment system rewards doing more, irrespective of whether doing more results in more good than harm, and certainly irrespective of whether we are getting good value in terms of improvements in health for the resources invested,” LeFevre writes. “Every dollar spent on health care is someone’s income stream. In any move to do less, there will be efforts from those who lose income to push back.”
‘What will we do?’
As I’ve noted here before, cervical cancer screening is one of the great success stories of modern medicine. Since the test was developed in the 1940s, the death rate in the United States from cervical cancer has plummeted 70 percent. Yet the test is not without potential harms. It produces a large number of false positives, which can lead to unnecessary treatments that sometimes affect future pregnancies.
“Finding an approach to screening that has the right balance of benefit and harm across the screened population is our present challenge,” writes LeFevre. “Blind adherence to doing more whenever there is a possibility of good, no matter how removed that possibility is or how much harm is done in the process, should not be our approach. Cervical cancer screening is a prime example of where we can do less without compromising the health of our patients. National evidence-based guidelines are all in agreement. What will we do?”