Are You Worried Sick?

How vulnerable really are you to heart attack, stroke or breast cancer?

Assume that you are a 40-year-old man. What do you think the chances are that you will die of a heart attack or stroke in the next 10 years? (Please forgive the morbidity of the question; there is a purpose to this pop quiz.) The answer: just 4 out of 10,000 according to Drs. Steve Woloshin and Lisa Schwartz, authors of Know Your Chances. The chances that you will die in an accident before reaching your 50th birthday are 50 percent higher: 6 out of 10,000.

Nevertheless, many men remain convinced that they are at great risk of dying from vascular disease, particularly as they get older. In truth, even at age 60, the odds that a heart attack or stroke will end your life over the next decade are only 37 out of 10,000. Over that span, you are three times more likely to die of another cause — with the chance of a fatal accident (5 out of 10,000) just as high as the chance of a stroke. Moreover, for reasons we do not fully understand, the incidence of heart attacks is declining.

“Fifty years ago, heart attacks were a scourge. Everyone knew a working-age man who’d dropped dead from one,” writes Dr. Nortin Hadler in his new book, Worried Sick. Today “the decline in mortality from coronary artery disease is well documented.” In fact, it’s considered one of the biggest public health achievements of the last century.

There is one glaring exception: If you are a 60-year-old smoker, the chance of a fatal heart attack or stroke in the next 10 years climbs to 67 out of 10,000, and your chance of dying of lung disease rises to 59 out of 10,000. The moral? If you don’t like those odds, it’s time to quit smoking.

For many women, breast cancer is the great fear. Again, let’s look at the numbers. If you are a 35-year-old woman, what do you think the chances are that you will die of breast cancer before you turn 45? Just 1 out of 10,000 according to Woloshin and Schwartz. The chances that you will die in an accident over the next decade are twice as high: 2 out of 10,000.

Granted, as you grow older, your chances of dying from breast cancer rise, but so do your chances of dying from other causes. When you are 60, the odds that breast cancer will kill you over the next 10 years are 7 out of 10,000. Slim odds. The chances you will die of a heart attack are twice as high: 14 out of 10,000. Maybe you shouldn’t worry quite so much about breast cancer.

I was surprised by these numbers, because I thought breast cancer was a leading cause of death among women. This is because I have heard that 1 in 9 women will “get” breast cancer if they live to 85. But as Woloshin and Schwartz point out, this is one of those health messages that is “intended to be scary, warning us that we are surrounded by danger and hinting that everything we do or neglect to do brings us one step closer to cancer, heart disease and death.”

As a result, Americans are Worried Sick, writes Hadler. A professor of medicine and microbiology/immunology at the University of North Carolina, Chapel Hill, Hadler points out that “far less than 1 in 9 women will die of breast cancer, or even know that they ‘have’ it when they die.”

Unless they had a mammogram. Then they would probably find out and be treated — whether or not they need treatment. It turns out that two-thirds of women older than 55 who have breast cancer will die of something else. Here are the numbers: In order to prevent one cancer death among women over 55, 250 women have to be screened annually, beginning at age 55. But mammograms will also detect two other women with breast cancer who would not have died of the cancer. “In other words” Hadler says, “the screening will lead to the treatment of three women, for two of whom the treatment is unnecessary.”

“This is the best-case scenario for screening postmenopausal women,” Hadler explains. One out of 250 will be saved, and two out of 250 will be exposed to the risk and worry of treatment without deriving any benefit. Hadler sums up the findings: “Early detection [via a mammogram] makes less sense the older the woman, or the more morbidities [potentially fatal diseases] that she suffers. In such a circumstance, breast cancer is but one of the processes vying for the proximate cause of death and not the most likely to win.”

Moreover, there is no “best-case scenario” for screening younger women, unless they have a family history of early death from breast cancer. This, Hadler notes, is why “the American College of Physicians believes that the risks of unnecessary biopsies far outweighs the likelihood of saving a life,” and therefore does not recommend mammography before age 50 and suggests that women do not need to be screened after age 74. Similarly, the U.S. Preventive Services Task Force recommends mammography screening only every one to two years for women ages 50 to 69.

Cancer or Precancer?

Too often, Hadler warns, mammograms discover ductal carcinoma in situ (DCIS); “in situ” suggests that there is no discernible evidence that the cancer is spreading. By the 1970s, physicians were finding more and more cases of DCIS.

“It’s about this time that the notion of a ‘precancer’ really took hold,” Hadler observes. “Powerful surgeons writing in powerful journals were advocating mastectomy to expunge the risk, whatever its magnitude.” DCIS can become invasive, he acknowledges, “but low-grade, tiny DCIS lesions take their time to become invasive, even more time to become metastatic.

“It is defensible to excise DCIS if it is discovered in a younger patient,” he says. “That’s not the issue. The issues are what are the yield and iatrogenicity [the danger of inadvertently harming the patient] when trying [so] hard to discover DCIS in the first place?”

Today, “we are witnessing an epidemic of DCIS,” says Hadler. “In 1980, DCIS accounted for only 2 percent of breast cancers. Between 1973 and 1992, the age-adjusted incidence rate of DCIS increased nearly sixfold. Meanwhile, the age-adjusted rise in the incidence of invasive ductal cancer was only 34 percent. Women are not getting more cancers. Rather, U.S. women are getting more breast biopsies thanks to mammography.” And once diagnosed, “local excision is always recommended, often with some radiation therapy, chemotherapy or surgical exploration of the nodules.” And local excision can be extensive, to assure “clean margins.” Often, women then opt for painful, expensive breast reconstruction.

Since most cases of DCIS are now treated, there’s no way to determine how many would have gone on to become invasive. And what woman would opt to avoid treatment, when faced with the information from her mammogram?

How many of these women would have been better off if they had never known about the lesion? As Hadler points out, older women in particular are likely to die of something else before this type of cancer becomes invasive.

Nevertheless, Americans have been sold on the idea that early detection is best. Hadler says: “The public-awareness program for cancer has been far more successful in promoting enthusiasm than reason.” Research shows “Americans are willing to undergo screening without regard to the efficacy of the tests or the likelihood they will lead to unnecessary treatment.”

Popper’s Pupil

Who is Nortin Hadler, and why is he saying these terrible things about screening and early detection? Hadler is a scientist and a physician. He started his career as a geneticist, moved on to study immunochemistry, and spent his first decade on faculty as a physical biochemistry professor. Today, he is a professor of medicine and an attending rheumatologist at UNC hospitals. He has closed his laboratory, but he retains “a keen appreciation for the scientific method at its most rigorous.”

At the same time, Hadler knows how fallible medical science is. A student of Karl Popper, the philosopher of science who taught that “truth is only the hypothesis that is yet to be disproved,” Hadler knows that today’s received wisdom may be replaced tomorrow.

Not long ago, he points out, “tonsils were removed because they were swollen and uteruses because they were lumpy.” We were wrong. Throughout the 1990s, oncologists thought that bone-marrow transplants would help breast cancer patients — and thousands of women suffered needlessly. More recently, we are realizing that when you consider the risks as well as the benefits, we may have been overly optimistic about mammograms as the answer to breast cancer. A few women are saved; many others are hurt. Or as an Australian study declared not long ago: “Benefits and harms of screening mammography are relatively finely balanced.”

Until quite recently, the National Cancer Institute and the American Cancer Society recommended PSA testing for early-stage prostate cancer for average-risk men over 50. Now, they don’t.

In medicine, scientific progress is not simply a matter of accumulating of knowledge. Often, advances mean unlearning what we thought we knew — and replacing that knowledge with a new, temporary truth. Sometimes the new truth is misleading; sometimes it will apply only to some patients. Always, we have to be ready to see it replaced.

Hadler explains that he wrote Worried Sick not for people who are seriously ill but for the “worried well.” Hadler wants to help us cope with knowing that we are mortal without letting the fear of death shadow our lives as we fret over each and every symptom — be it “heartburn, a peculiar sensation or a realization of our physical limits.”

His goal is to “bolster the personal resources that facilitate coping” with the ills that flesh is heir to. “And our coping is in dreadful need of bolstering,” he adds. “The wealth of information disseminated by all sorts of health care vendors, including those in the medical profession, may be intended as helpful but often is not.

“Yes, we will all die,” Hadler adds. “The issue for me is not so much how or why we die, but when and how we lived.” But in our health care system, and in the minds of the average person, “the proximate cause of death is foremost, so that great energy and great wealth is expended trying to spare you death from a particular cause without considering whether you will die at the same time from some other cause.”

Ultimately, Hadler wants to help us cope with not being perfectly well — and knowing that we are mortal without being “worried to death” about dying. “No one should be as concerned about the proximate cause of their demise as they are about the likelihood their course in life will be satisfying. It matters little what carries one off, as long as it was her or his time and the journey was gratifying.”

Maggie Mahar is the author of Money-Driven Medicine and health care fellow at the Century Foundation where she writes, where this article first appeared. Alex Gibney, director of Enron: The Smartest Guys in the Room, has just finished a documentary of her book, Money-Driven Medicine.

Where You Get Your Care

It turns out there are vast differences in the amount and type of care that patients receive, not based so much on their diagnoses, but more on where the patient happens to live.

A white paper prepared by the Dartmouth Health Atlas in December 2008 states that: “In the absence of evidence, the prevailing cultural assumption that more medical care is better takes hold, leading physicians unconsciously to use available resource capacity up to the point of its exhaustion. This assumption is amplified in a fee-for-service environment that pays providers more for doing more.”

That is, if ORs and MRIs are available, why not use them? After a while, medical practice patterns take hold regionally to produce localized standards of practice. Problem is, these local standards may have little to do with current research.

For more than 12 years, researchers at the Dartmouth Health Atlas have been compiling and comparing data on Medicare patients’ treatment and outcomes, based on where they live. And what the researchers have found is puzzling. For example, according to the Atlas, in 2002-03, the rate of surgery for prostate glands with benign growths among male Medicare enrollees in Spokane was about twice as high as for men with the same condition in Seattle. Back surgery rates for Medicare patients in Spokane were 50 percent higher than in Seattle, while coronary artery bypass grafts were about 30 percent higher for Medicare enrollees in Spokane. Other conditions for which treatment varies significantly within the state or between Washington and other states include severe osteoarthritis of the knee and hip, gall bladder disease, and cancer of the breast and reproductive organs.

— Anne McGregor

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