Why the U.S. Spends So Much More Than Other Nations on Health Care

Studies point to a simple reason, the prices, not to the amount of care. And lowering prices would upset a lot of people in the health industry.


The United States spends almost twice as much on health care, as a percentage of its economy, as other advanced industrialized countries — totaling $3.3 trillion, or 17.9 percent of gross domestic product in 2016.

But a few decades ago American health care spending was much closer to that of peer nations.

What happened?

A large part of the answer can be found in the title of a 2003 paper in Health Affairs by the Princeton University health economist Uwe Reinhardt: “It’s the prices, stupid.

The study, also written by Gerard Anderson, Peter Hussey and Varduhi Petrosyan, found that people in the United States typically use about the same amount of health care as people in other wealthy countries do, but pay a lot more for it.

Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute, studies how health systems from various countries compare in terms of prices and health care use. “What was true in 2003 remains so today,” he said. “The U.S. just isn’t that different from other developed countries in how much health care we use. It is very different in how much we pay for it.”


The Best Health Care System in the World: Which One Would You Pick?

Assessing the systems in eight countries can inform the debate in the U.S. over universal coverage.

A recent study in JAMA by scholars from the Institute for Health Metrics and Evaluation in Seattle and the U.C.L.A. David Geffen School of Medicine also points to prices as a likely culprit. Their study spanned 1996 to 2013 and analyzed U.S. personal health spending by the size of the population; its age; and the amount of disease present in it.

They also examined how much health care we use in terms of such things as doctor visits, days in the hospital and prescriptions. They looked at what happens during those visits and hospital stays (called care intensity), combined with the price of that care.

The researchers looked at the breakdown for 155 different health conditions separately. Since their data included only personal health care spending, it did not account for spending in the health sector not directly attributed to care of patients, like hospital construction and administrative costs connected to running Medicaid and Medicare.

Over all, the researchers found that American personal health spending grew by about $930 billion between 1996 and 2013, from $1.2 trillion to $2.1 trillion (amounts adjusted for inflation). This was a huge increase, far outpacing overall economic growth. The health sector grew at a 4 percent annual rate, while the overall economy grew at a 2.4 percent rate.

You’d expect some growth in health care spending over this span from the increase in population size and the aging of the population. But that explains less than half of the spending growth. After accounting for those kinds of demographic factors, which we can do very little about, health spending still grew by about $574 billion from 1996 to 2013.

Did the increasing sickness in the American population explain much of the rest of the growth in spending? Nope. Measured by how much we spend, we’ve actually gotten a bit healthier. Change in health status was associated with a decrease in health spending — 2.4 percent — not an increase. A great deal of this decrease can be attributed to factors related to cardiovascular diseases, which were associated with about a 20 percent reduction in spending.

This could be a result of greater use of statins for cholesterol or reduced smoking rates, though the study didn’t point to specific causes. On the other hand, increases in diabetes and low back and neck pain were associated with spending growth, but not enough to offset the decrease from cardiovascular and other diseases.

Did we spend more time in the hospital? No, though we did have more doctor visits and used more prescription drugs. These tend to be less costly than hospital stays, so, on balance, changes in health care use were associated with a minor reduction (2.5 percent) in health care spending.

That leaves what happens during health care visits and hospital stays (care intensity) and the price of those services and procedures.

Did we do more for patients in each health visit or inpatient stay? Did we charge more? The JAMA study found that, together, these accounted for 63 percent of the increase in spending from 1996 to 2013. In other words, most of the explanation for American health spending growth — and why it has pulled away from health spending in other countries — is that more is done for patients during hospital stays and doctor visits, they’re charged more per service, or both.

Though the JAMA study could not separate care intensity and price, other research blames prices more. For example, one study found that the spending growth for treating patients between 2003 and 2007 is almost entirely because of a growth in prices, with little contribution from growth in the quantity of treatment services provided. Another study found that U.S. hospital prices are 60 percent higher than those in Europe. Other studies also point to prices as a major factor in American health care spending growth.

There are ways to combat high health care prices. One is an all-payer system, like that seen in Maryland. This regulates prices so that all insurers and public programs pay the same amount. A single-payer system could also regulate prices. If attempted nationally, or even in a state, either of these would be met with resistance from all those who directly benefit from high prices, including physicians, hospitals, pharmaceutical companies — and pretty much every other provider of health care in the United States.

Higher prices aren’t all bad for consumers. They probably lead to some increased innovation, which confers benefits to patients globally. Though it’s reasonable to push back on high health care prices, there may be a limit to how far we should.


Three Steps Toward a More Sustainable Path for Targeted Cancer Drugs

Spending on cancer drugs in the United States has increased substantially over the past 5 years, from $26 billion in 2012 to more than $45 billion in 2016.1 Targeted cancer drugs, including small molecules, monoclonal antibodies, and other therapies based on genomic and related analyses, contributed 60% of this spending growth.2 One estimate suggests that by 2021, cancer drugs will comprise one-quarter of the US late-stage pharmaceutical research and development pipeline, and 87% of these products will be targeted agents.2

Imatinib, the small-molecule oral tyrosine kinase inhibitor for chronic myeloid leukemia (CML), is often cited as the model targeted cancer drug; imatinib is highly effective and has reduced toxicity vs previous therapies. For patients with CML treated with imatinib, overall 10-year survival is 84%.3 Introduction of imatinib was associated with a reduction in US age-adjusted CML deaths per 100 000 persons from 0.9 in 1996 to 0.4 in 2006. In 2015, the Medicare estimated monthly price for imatinib was $9299.4

Yet most targeted cancer drugs do not extend life to nearly the same degree. Even though many cancer drugs show improvement in surrogate measures, such as progression-free survival, substantial improvements in overall life expectancy have been rare. For example, in 2017, neratinib was approved for patients with early-stage breast cancer after improving invasive disease–free survival by 2% (from 92% to 94%) after 2 years of follow-up, without published survival data.5 The estimated monthly price of neratinib is $10 500.

Imatinib exemplifies the promise of targeted therapy, whereas neratinib exemplifies the concern: marginally effective treatments that, in aggregate, strain US health care spending. The distorted pricing of marginally effective drugs risks crowding out the capacity of the US health system to pay for highly effective cancer drugs or other therapies of public health importance, potentially jeopardizing valuable innovation and escalating out-of-pocket expenses. The combination of high prices and marginal effectiveness is unsustainable.

We propose 3 steps to promote targeted cancer drugs that yield meaningful clinical benefits while reducing overall price growth. The recommendations are informed by discussions of a group of experts from health care economics, policy, law, and regulation; cancer research and medicine; patient advocacy; and the pharmaceutical and insurance industries.

The FDA Should Define Minimum Clinically Meaningful Effect Sizes

The FDA has 2 pathways to approve new drug applications. The regular approval pathway is based on demonstration of “clinical benefit,” which is defined as prolongation of life, a better life, or “an established surrogate.” The accelerated approval pathway, in contrast, is based on a surrogate measure reasonably likely to predict clinical benefit. In 2007, the FDA issued guidance on cancer trial end points to support claims of benefit. The guidance referenced approval as being “highly dependent on … effect size” but did not specify minimum effect sizes.6 An essential question thus remains unanswered: what minimum effect size defines meaningful benefit? This ambiguity is particularly problematic in increasingly common scenarios, such as when new targeted cancer drugs demonstrate statistically significant but clinically questionable improvements in surrogate measures.

The FDA should develop guidance on minimum clinically meaningful effect sizes for cancer drugs. This would clarify prior FDA guidance and move from the current uncertain concept of meaningful clinical benefit to a consensus-driven definition. The agency could empanel multidisciplinary advisory councils of scientists, oncologists, patient advocates, and industry representatives to achieve this aim.

Clinical experts already support the principle. After convening work groups to define clinically meaningful outcomes for 4 malignancies, the American Society for Clinical Oncology (ASCO) endorsed a minimum absolute improvement of 3 to 6 months in overall survival over best available treatment for drug trials among patients with metastatic disease. Guidance could separately address cases in which, despite little or no change in median overall survival or hazard ratios, small proportions of patients experience large gains and the challenge of estimating benefits when pivotal trials involve head-to-head comparisons against active controls, thereby potentially underestimating the overall efficacy of novel agents.

By defining norms, the FDA would encourage manufacturers to design trials that demonstrate clinically meaningful benefits. The FDA could consider these thresholds in weighing benefits and risks for the purpose of approval decisions, payers could use them to better bargain on price and formulary with drug makers, guideline writers could use them to prioritize among drugs with similar indications, and clinicians and patients could use them to improve shared decision making.

Medicare Should Negotiate for Targeted Cancer Drugs

Medicare is the largest purchaser of cancer drugs. Medicare pays for targeted cancer drugs through Part B, which covers infused drugs, and Part D, which covers prescription drugs. The law, however, prevents Medicare from directly negotiating with manufacturers on drug prices. Instead, in Part B, Medicare pays for drugs under the buy-and-bill system, in which hospitals and physician offices purchase drugs and bill Medicare at 6% above the average sales price. In Part D, Medicare plan sponsors, typically insurance companies or pharmacy benefit managers, manage pricing negotiations. The law also effectively ensures that Medicare Parts B and D cover all FDA-approved cancer drugs for on-label indications as well as off-label indications listed in approved compendia, whether through “reasonable and necessary” language in Part B or “protected class” language in Part D. Consequently, Medicare cannot exercise pricing leverage through coverage determinations or formulary design.

Congress could direct the Centers for Medicare & Medicaid Services (CMS) to conduct a demonstration project in which Medicare negotiates the prices of targeted cancer drugs paid for by Parts B and D. The demonstration also should authorize Medicare to apply limited formulary tools, such as coverage restrictions or tiering, to marginally effective targeted cancer drugs or targeted cancer drugs with therapeutic alternatives. Alternative drugs should include not only biosimilars but also chemically or biologically different drugs with overlapping indications and benefit-risk profiles. Protected classes could be narrowed to permit exclusion of drugs with overlapping indications or mechanisms of action. An appeals process could address special cases. Advisory panels with diverse and relevant expertise, including patient advocates, could inform pricing discussions and formulary design.

Granting Medicare the ability to negotiate on price and use a formulary is politically challenging. The National Academies, the Medicare Payment Advisory Commission, and others have recommended that the federal government use its bargaining power to negotiate drug prices. This step could be operationalized either by Congress granting CMS authority as a single entity to negotiate with pharmaceutical companies or through competitive bidding. The program could phase in over multiple years, starting with clinical settings where therapeutic alternatives exist. This approach could foster evaluation and refinement based on lessons learned.

Guidelines Should Prioritize Drugs by Benefit and Price

Physicians and patients should be able to consider the prices of targeted cancer drugs along with their benefits and harms when selecting treatments. Evidence-based guidelines are best positioned to meet this need. Such guidelines should demarcate marginally effective from highly effective drugs. In addition, for cases in which 2 or more drugs or regimens have comparable benefit-harm profiles for an indication, guidelines should prioritize the lower-priced alternative.

Although organizations that produce practice guidelines have taken steps to incorporate costs, they should go further. ASCO could extend its value framework, which displays cost alongside net health benefit, to prioritize treatment regimens in its clinical practice guidelines. The National Comprehensive Cancer Network could rank-order treatment regimens in its practice guidelines, informed by its Evidence Blocks, which already evaluate affordability alongside other measures. In addition, other groups have developed reports on pricing, effectiveness, and value for cancer treatments and drugs more broadly that merit the attention of guideline writers.

Guidelines should also promote price transparency. To do so, they could report the estimated monthly price of cancer drugs, perhaps by using the amount reimbursed by Medicare. Although estimates of out-of-pocket expenses would be most useful to patients, and prices vary by payer, the Medicare payment amount correlates with patient co-insurance expenses and has the advantage of being a reference standard. Practice guidelines that rank-order targeted cancer drugs by clinical benefit and price and deprioritize marginally effective drugs could be influential, informing insurer value-based reimbursement programs and clinical pathways.


Successfully implementing steps to limit the use of high-priced, marginally effective drugs will be difficult; patients with life-threatening diseases may expect access to drugs despite their high costs and limited benefits. Nevertheless, the ultimate beneficiaries of these changes will be patients, who deserve the substantial efficacy, reduced toxicity and enhanced value that were the original promise of targeted cancer drugs.

Source: JAMA


Vitamin and Mineral Supplements –What Clinicians Need to Know : JAMA


Omega-3 Supplements do not have CVD benefits : JAMA


Glucose self-monitoring of no help in glycaemic control

Glycaemic control is no better in diabetic patients who monitor their blood glucose than in those who do not, the open label randomized MONITOR trial has shown.

There were no significant differences in HbA1c levels or in health-related quality of life (HRQoL) among patients with non-insulin-treated type 2 diabetes (T2D) who did self-monitoring of blood glucose (SMBG) compared with those who did not at 1 year. Hypoglycaemia frequency, healthcare utilization, and insulin initiation were also comparable between groups. [JAMA Intern Med2017;doi:10.1001/jamainternmed.2017.1233]

“Even tailored feedback through messaging did not provide any advantage in glycaemic control,” said lead investigator Dr Laura Young from the University of North Carolina at Chapel Hill School of Medicine in North Carolina, US. “These findings suggest that glucose monitoring should not be a routine in patients with non-insulin-treated T2D.”

The MONITOR trial included 450 adult patients (age >30 years) with T2D (HbA1c 6.6-9.5 percent) who were not treated with insulin and randomized to SMBG once daily, SMBG once daily with enhanced feedback, or no SMBG. Neither type of self-monitoring showed advantage over no self-monitoring in terms of HbA1c reduction at 1 year (SMBG with messaging vs no SMBG, −0.09 percent; SMBG vs no SMBG, −0.05 percent; average over SMBG arms vs no SMBG, −0.07 percent).

Of note, the coprimary endpoint of HRQoL was also comparable between mental and physical estimated adjusted mean difference scores (SMBG with messaging vs no SMBG, −0.83 points; SMBG vs no SMBG, −0.05 points; average over SMBG arms vs no SMBG, −0.44 points for the physical score whereas SMBG with messaging vs no SMBG, −0.19 points; SMBG vs no SMBG, 0.19 points; average over SMBG arms vs no SMBG, 0 points for the mental score).

Previous studies assessing the efficacy of self-monitoring in diabetic patients have shown contradictory results. “Proponents of routine SMBG postulate that testing promotes better awareness of glucose levels, leading to improvements in diet and lifestyle,” said Young. “However, our findings showed that SMBG does not help at all.”

Sensitivity analysis at 6 months showed slight differences in mean HbA1c levels between the intervention and control groups (-0.33 percent; p=0.002). However, improvements in glycaemic control regressed back to baseline from 6 through 12 months.

Adverse events reported included severe hypoglycaemia (1), hospitalizations (62), and deaths (2). However, none was treatment-related.

“As the first large pragmatic US trial of SMBG, our findings provide evidence to guide patients and clinicians in making important clinical decisions about routine blood glucose monitoring,” said Young. “[Both] should engage in a dialogue regarding SMBG … it should not be routine for most patients with non-insulin-treated T2D. The findings should not also be extrapolated to patients taking insulin,” she cautioned.

In an accompanying editorial, Drs Elaine Khoong of the University of California, San Francisco, US and Joseph Ross of Yale University School of Medicine, New Haven, Connecticut, US said the study supports the “less is more” approach to glucose monitoring considering that there are no clear benefits accrued.

Source:[JAMA Intern Med2017;doi:10.1001/jamainternmed.2017.1251]

Yale and Harvard Study: Gun Violence Is Public Health Epidemic.

Article Image
Close contact to guns through family or acquaintances puts you naturally closer to gun violence.

A study published in JAMA claims gun violence spreads like an infectious disease. The research team – Yale Sociology professor Andrew Papachristos and Harvard students Ben Green and Thibault – looked at over 11,000 shootings in Chicago from 2006 – 2014. The researchers concluded that gun use spreads like a virus due to social affiliation with others, with Papachristos telling Gizmodo: “You don’t catch a bullet like you catch a cold, [but] the power of this analogy is really thinking about the precision with which it moves through a population.”

The total network studied includes over 138,000 individuals. The likelihood a gun is fired is partly dependent on the network you’re involved with. For this reason, Papachristos concludes gun violence should be treated “as a public health epidemic and not just a policing problem.”

Criticism over ‘stop and frisk’ policies in the New York City Police Department is well documented. Across the nation police officers have been captured on camera perpetuating unjust violence, which has resulted in numerous marches, online movements, protests, and counter-violence. Yet rates of gun violence are not going down. It’s more than a policing problem.

If trends continue—nothing hints they won’t—over 33,000 people will die and 200,000 will get injured this year in the United States, far exceeding any other nation. That the 33,000 number bundles together homicides and suicides doesn’t make it any less relevant or problematic. Still, diseases with less impact receive more funding, including HIV, Parkinson’s disease, malnutrition, and intestinal infections. In fact, the other two major causes of death receiving less funding are drowning and falling—pretty self-explanatory, even if conditions vary.

Gun violence is not so easily explained. Second Amendment pundits argue that it’s people, not bullets, causing problems; some conclude it should be treated as a mental health issue on a case-by-case basis. But that’s not how humans operate. No one lives in a vacuum. We’re constantly influenced by our environment and, more specifically, those we navigate our environment alongside.

Yet funding as to why this is and what can be done to stop it pale in comparison to other diseases. Based on deaths alone, gun violence should receive $1.4 billion for research over a decade. The amount it received during the nine years this study ran? Twenty-two million dollars.

David Stark, a medical director at Mount Sinai, parallels gun violence to motor vehicle accidents:

Those kill about the same number of people, but that has been decreasing substantially. … All of that really starts from essential public research that determines the proximate causes of accidents — and it’s only with research that you can start to develop plans and policies and initiatives.

With the incoming administration such policies seem impossible. Of all the lobbying groups, the NRA’s ‘rating guide’ of elected officials is one of the most insidious framing of arguments (that turn into policy). The rallying cry of ‘personal rights’ is easily confused by the true message, ‘sell more guns.’ In this capitalistic thrust forward a nation continues to be held captive by a preventable and treatable disease, if only the people in charge of seeking a cure would live up to the responsibility of doing so.

This is not to imply that a silver bullet would become immediately apparent with a few studies. But it would be a step in the right direction. Often people needing a doctor most visit least, choosing denial of their condition over their health. A small but powerful segment of the American population remains in denial about gun violence even though the doctor is right around the corner.


Lead Exposure In Childhood May Blunt Thinking Skills For Decades.

State and federal policies now limit the use of lead in gasoline, paint and plumbing, but children can still ingest the metal through contaminated soil. The effects of even fairly small amounts can be long-lasting, the evidence suggests.
Christin Lola/Getty Images/iStockphoto

Exposure to lead as a child can affect an adult decades later, according to a study out Tuesday that suggests a link between early childhood lead exposure and a dip in a person’s later cognitive ability and socioeconomic status.

Lead in the United States can come from lots of sources: old, peeling paint; contaminated soil; or water that’s passed through lead pipes. Before policies were enacted to get rid of lead in gasoline, it could even come from particles in the fumes that leave car tailpipes.

And when lead gets into a human body, it can mess with brain development, decades of research has shown.

“It’s toxic to many parts of the body, but in particular in can accumulate in the bloodstream and pass through the blood brain barrier to reach the brain,” says the study’s first author, Aaron Reuben, a graduate student in clinical psychology at Duke University.

Reuben and his colleagues published the results of a long-term study on the lingering effects of lead.

Researchers had kept in touch with about 560 people for decades — starting when they were born in Dunedin, New Zealand, in the 1970s, all the way up to the present.

As children, the study participants were tested on their cognitive abilities; researchers determined IQ scores based on tests of working memory, pattern recognition, verbal comprehension and ability to solve problems, among other skills.

When the kids were 11 years old, researchers tested their blood for lead. (That measurement is thought to be a rough indicator of lead exposure in the few months before the blood draw.)

As Reuben and his colleagues write in this week’s issue of JAMA, the journal of the American Medical Association, they found a subtle but worrisome pattern in the data.

As expected, the participants in the study who had low blood levels as children had an adult IQ that was as high as when they were kids.

However, Reuben says, children who experienced higher lead exposures “saw their intellectual abilities decline from their baseline starting point” as time wore on.

And, he adds, “people who saw that decline also experienced downward social mobility.”

The children who’d had high lead exposure — defined at the time as more than 10 micrograms per deciliter of blood — were more likely than the other kids to go on to have jobs that required slightly less education and brought in a little less income compared to their parents’ jobs.

In Reuben’s study, every 5 microgram increase in lead concentration in the blood at age 11 corresponded to a drop in IQ of 1.6 points at age 38 — primarily because of a drop in scores on perceptual reasoning and working memory. (Today the health standards for lead are stricter; 5 micrograms per deciliter is considered high exposure, according to the Centers for Disease Control and Prevention, and no amount of lead is considered safe.)

The dips in IQ and in socioeconomic status were mild. But, Reuben says, “even small changes in IQ had some significant influence on the course that people’s lives took.”

There is one thin silver lining to the study, points out David Bellinger, a neuropsychologist and environmental epidemiologist with Boston Children’s Hospital and Harvard Medical School and a longtime researcher of lead’s effects: The findings lend credence to an estimate that, in the U.S. over the last 40 years, interventions to reduce lead exposure may have “raised the mean IQ in adults by as much as 4.5 points.”

Still, Bellinger notes in an editorial accompanying the JAMA study that progress has not solved the problem.

There’s no reason to think the findings in the New Zealand study wouldn’t hold for an American population, too, he says — and they don’t just apply to the generation now entering middle age.

Years after policies went into place in the U.S. limiting or eliminating lead in paint, plumbing and gasoline, there’s still a lot of legacy lead hanging around, which kids can still ingest today.

“We will continue to have to deal with the impact of lead on children — and adults — until we address these legacy sources of lead that are still in our environment,” Bellinger says.

And unlike in New Zealand, where lead exposure appears to have been an equal opportunity toxin — impacting all socioeconomic groups — in the U.S., children living in low-income areas tend to be most at risk.

“In Flint and other places we know now experiencing higher lead exposures than we would like, most of these kids are starting out already disadvantaged in life,” Reuben says.

This study, he says, suggests that exposure to lead may be one more thing holding them back for decades to come.


Repeated eye injections for age-related macular degeneration associated with increased risk for glaucoma: JAMA

Patients with age-related macular degeneration who received seven or more eye injections of the drug bevacizumab annually had a higher risk of having glaucoma surgery, according to a study published online by JAMA Ophthalmology. The advent of intravitreous (in the vitreous, the fluid behind the lens in the eye) anti-vascular endothelial growth factor (VEGF) injections to treat common causes of vision loss, such as exudative (wet) age-related macular degeneration (AMD) and diabetic macular edema.

Repeated eye injections for age-related macular degeneration associated with increased risk for glaucoma: JAMA

Read more at Medical Dialogues: Repeated eye injections for age-related macular degeneration associated with increased risk for glaucoma: JAMA http://speciality.medicaldialogues.in/repeated-eye-injections-for-age-related-macular-degeneration-associated-with-increased-risk-for-glaucoma/

National Cancer Institute and JAMA Medical Journal Admit: “Oops… It Wasn’t Cancer After All”

After decades of wrongful cancer diagnoses and treatments, and millions harmed, the National Cancer Institute and high gravitas journals like JAMA (the Journal of the American Medical Association) finally admit they were wrong all along.

The National Cancer Institute Admits ''Oops... It Wasn't Cancer After All''

Back in 2012, The National Cancer Institute convened an expert panel to evaluate the problem of cancer’s misclassification and subsequent overdiagnosis and overtreatment, determining that millions may have been wrongly diagnosed with “cancer” of the breast, prostate, thyroid, and lung, when in fact their conditions were likely harmless, and should have been termed “indolent or benign growths of epithelial origin.” No apology was issued. No major media coverage occurred. And more importantly, no radical change occurred in the conventional practice of cancer diagnosis, prevention, or treatment.

Essentially, in one sleight of the semantic hand, entire swaths of the U.S., and global population, who thought they had “lethal cancer,” and were subsequently treated for it, often with violent procedures and treatments, were being told that“oops… we got that wrong. You never had cancer after all.”

If you look at the problem through just breast cancer overdiagnosis and overtreatment in the U.S. over the past 30 years, it has been estimated that approximately 1.3 million women were wrongly treated. Most of these women still have no idea they were victims, and many have identified with their “aggressors” in Stolkholm syndrome like fashion, because they think their “lives were saved” by unnecessary treatment, when in fact the side effects, both physical and psychological, have almost certainly reduced both the quality and duration of their lives.

When the National Cancer Institute report was released, it was a sort of vindication for those of us who had been advocating the position that a commonly diagnosed form of so-called “early breast cancer” known as ductal carcinoma in situ was in fact not inherently malignant and should not have warranted the conventional treatments of lumpectomy, mastectomy, radiation, and chemotherapy. I based this position on available research on the natural history of DCIS, and the extremely high survival rates from DCIS, as well as the fact that breast cancer-related mortality had not declined in pace with the expansion of so-called “zero” or “early stage” cancers detected through mammography screenings, as would be expected if these diagnoses actually represented harmful clinical entities.

Since then, I have watched the problem of overdiagnosis and overtreatment closely. I get daily updates from pubmed.gov on the topic, and increasingly, high impact and gravitas journals are reporting on this highly concerning phenomenon. Particularly relevant is a review published late last year, which I reported on in my article titled, “Astounding Number of Medical Procedures Have No Benefit, Even Harm – JAMA Study.”

The JAMA study found that a wide range of standard medical procedures and interventions that millions are subjected to annually, are not evidence-based, as commonly assumed, and have little to no benefit, and may even be causing significant harm. As a result, I now believe that good medicine often involves doing as much as nothing as possible. I also think that people should be aware that any conventional cancer diagnosis has the ability to exert lethal harm via thenocebo effect, regardless of its accuracy (i.e., even a misdiagnosis can result in lethal consequences because the power of belief).

Thyroid Cancer Epidemic Caused by Misinformation, Not Cancer

Another topic I have been trying to spread awareness about is thyroid cancer overdiagnosis and overtreatment. When I first reported on this two years ago in my article, Thyroid Cancer Epidemic Caused by Misinformation, Not Cancer, a series of compelling studies from around the world revealed that the rapid increase in diagnoses in thyroid cancer reflected their misclassification and misdiagnosis. As was the case with screening detected breast and prostate “cancers,” and even many ovarian “cancers,” the standard of care often required the removal of the organ, as well as irradiation and chemotherapy — two interventions known to promote not inhibit cancer.

As is typical of research that undermines the conventional standard of care, there has been little reporting on the topic. That is, until now.

On April 14th 2016, in an article titled “Its Not Cancer: Doctors Reclassify a Thyroid Tumor,” the New York Times reported on a new study published in JAMA Oncology which should forever change the way we classify, diagnosis and treat a common form of “thyroid cancer”:

An international panel of doctors has decided that a type of tumor that was classified as a cancer is not a cancer at all.

As a result, they have officially downgraded the condition, and thousands of patients will be spared removal of their thyroid, treatment with radioactive iodine and regular checkups for the rest of their lives, all to protect against a tumor that was never a threat.

Their conclusion, and the data that led to it, was reported Thursday in the journal JAMA Oncology. The change is expected to affect about 10,000 of the nearly 65,000 thyroid cancer patients a year in the United States. It may also offer grist to those who have been arguing for the reclassification of some other forms of cancer, including certain lesions in the breast and prostate.

The reclassified tumor is a small lump in the thyroid that is completely surrounded by a capsule of fibrous tissue. Its nucleus looks like a cancer but the cells have not broken out of their capsule, and surgery to remove the entire thyroid followed by treatment with radioactive iodine is unnecessary and harmful, the panel said. They have now renamed the tumor. Instead of calling it “encapsulated follicular variant of papillary thyroid carcinoma,” they now call it “noninvasive follicular thyroid neoplasm with papillary-like nuclear features,” or NIFTP. The word “carcinoma” is gone.

Many cancer experts said the reclassification was long overdue. For years there have been calls to downgradesmall lesions in the breast, lung and prostate, among others, and to eliminate the term “cancer” from their name. But other than the renaming of an early stage urinary tract tumor in 1998, and early stage ovarian and cervical lesions more than two decades ago, no group other than the thyroid specialists has yet taken the plunge.

In fact, said Dr. Otis Brawley, chief medical officer at the American Cancer Society, the name changes that occurred went in the opposite direction, scientific evidence to the contrary. Premalignant tiny lumps in the breast became known as stage zero cancer. Small and early-stage prostate lesions were called cancerous tumors. Meanwhile, imaging with ultrasound, M.R.I.’s and C.T. scans find more and more of these tiny “cancers,”especially thyroid nodules.

“If it’s not a cancer, let’s not call it a cancer,” said Dr. John C. Morris, president-elect of the American Thyroid Association and a professor of medicine at the Mayo Clinic. Dr. Morris was not a member of the renaming panel.

Dr. Barnett S. Kramer, director of the division of cancer prevention at the National Cancer Institute, said, “There’s a growing concern that many of the terms we use don’t match our understanding of the biology of cancer.” Calling lesions cancer when they are not leads to unnecessary and harmful treatment, he said.

The article goes on to discuss the fact that, while some major medical centers are starting to treat encapsulated thyroid tumors less aggressively, this is still not the norm in the rest of the country. It is a consistent pattern that there is a lag of over a decade between changes in evidence and the clinical practice of medicine, which therefore makes medical practice far less “evidence-based” than is commonly claimed and/or assumed.

Clearly, the truth about cancer’s true nature, and the cancer industry’s misrepresentations, is beginning to come to light via the very institutions like JAMA and the major media who have been responsible, historically, for generating so many commonly held misconceptions on the topic.

2014 Top Stories in Primary Care: Adding Insulin, Adding Mortality

The story in 2014 that changed my practice the most was a retrospective VA study published in JAMA last June that looked at 178,341 patients with diabetes treated with metformin monotherapy.1 When more control was needed, insulin was added to the regimen of 2984 patients and a sulfonylurea was added to the regimen of 39,990. When these two groups were compared, the addition of insulin was associated with a 1.44 risk for all-cause mortality and a 1.85 risk for death from cancer.

Type 2 diabetes often starts as a metabolic syndrome of insulin resistance. Elevated levels of insulin promote weight gain and systemic inflammation. It makes sense that adding more insulin to the regimen of someone who is already resistant would require doses that would exacerbate the imbalance of this metabolic process.

The challenge for clinicians is that many medical systems are looking at our patients’ HbA1c levels to see if we have their diabetes under adequate control, and the most effective medicine we can use to lower HbA1c is insulin. In fact, another article in the same issue of JAMA showed this to be the case.2

So, what is one to do? If I use the most effective drug to look like I am a good doctor, I may be more likely to increase the risk for death and cancer in my diabetic patients. The best way to reverse this metabolic process and reduce the risk for death and cancer is through weight loss, good nutrition, and movement. But if the patient on metformin needs more help, I will consider a sulfonylurea; however, this can cause weight gain and hypoglycemia. Therefore, I also keep a glitazone, a glucagon-like peptide-1 receptor agonist, or a dipeptidyl pepdidase-4 inhibitor at the ready.

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