Healthy? Think Again
New ways of diagnosing illness are changing the rules of medicine. How to sort out what it all means:
The growing debate over preconditions would be different if such diagnoses resulted only in lifestyle advice from physicians. There's little downside to advising women with osteopenia to increase their consumption of calcium-rich foods and stop smoking. But many doctors figure it's safer to write a prescription, and many low-risk patients--bombarded by pharmaceutical ads that show young and healthy people taking drugs--wind up taking medications that at best may not work and at worst may have harmful side effects. Eric Bruce, a 43-year-old in Chicago, thought about those risks when he learned that his blood pressure--130/85--falls in the prehypertensive range. His cholesterol is about 220, somewhat high. But he exercises frequently--he's completed several Ironman triathlons and last week ran the Boston Marathon--eats well, and says he's got good genes. "Historically," he says, "my family members have passed away near the age of 100." For now, Bruce is staying away from medication. Mary Walker, a 39-year-old in Redwood City, Calif., had similar thoughts when her doctor prescribed a daily steroid inhaler for her mild asthma. She's not automatically opposed to drugs but decided that her symptoms weren't bad enough to risk the potential side effects of long-term steroid use. Her instincts, as it turned out, were right: This month a new study showed that people with such mild, persistent asthma could find relief equal to daily medication just by using an occasional inhaler, as she does.
Weighing the risks and benefits of treatment is more agonizing, obviously, when the diagnosis is more serious. The incidence of ductal carcinoma in situ , an early form of breast cancer that hasn't yet invaded the surrounding tissue, has skyrocketed recently. Data show that most women with DCIS don't develop invasive cancer, but the treatment is still nearly always aggressive--mastectomy, lumpectomy, or radiation. There is plenty of debate about how to approach and screen for DCIS, but studies by Lisa Schwartz, codirector of the VA Outcomes Group, and her coauthor, Steven Woloshin, found that people view cancer screening as a nearly unqualified good. "We were surprised at how strongly people feel about this," she says. "We've spent so long convincing them that earlier is better, and when someone tries to change that without explaining . . . there's a lot of cynicism."
Cynicism often comes down to cost. Many people feel that cutbacks in treatment or diagnosis are merely attempts to save money. But what if treatments are unproven? The asthma study, for example, suggested that annual medication costs would be $2 billion lower if all those people took inhaled steroids only when symptoms flared up. Paying for everyone to hedge their bets with unproven treatments, many doctors say, simply can't go on. "What we are doing is not sustainable," says Nortin Hadler, a rheumatologist at the University of North Carolina-Chapel Hill and author of The Last Well Person. "It's about to implode. If it's been studied, and there is no evidence it works, it shouldn't be paid for. If it's been studied and there is evidence, that's not enough. I want to know whether the evidence will advantage my patient."
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