Monday, October 30, 2006

Germany plans to punish cancer patients who failed to undergo timely screening

The BMJ reports that Germany plans to penalise cancer patients who failed to undergo regular screening. That's very much in line with the country's policy to charge dental patients higher rates who failed to have regular check-ups.
The argument is obviously that these patients had a good chance to prevent getting seriously ill, yet they chose not to do so by omitting to undergo screening. Timely detection of early stage cancer and early intervention dramatically reduce serious illness and death.
Invariably such a drastic policy has its critics. Hazel Thornton writes on that such a policy
'intrudes on an individual`s right to refuse an imperfect intervention that can result in false negative and false positive diagnoses; can lead to gross over-treatment; to psychological harm and false categorisation as `cancer patient`.'
Thornton's argument misses the obvious point that the harmful effects of some false negative and false positive diagnoses are by far outweighed by the majority of correct diagnoses resulting into early treatment. Of course, patients are entitled to refuse such testing, but surely if they do, it is not unreasonable to ask them to compensate other tax payers for the additional cost their behaviour is causing.

post scriptum: Given that this blog has no discussion forum, I have decided to post the below reply to this blog (with permission by the person posting it).
Your post on screening seem to imply that it is always cost-effective. Yet I haven't seen any numbers from you other than vague statements of how risks can justify the benefits. Have you done any calculations? You have to factor in that
1) cost of screening of millions of people
2) cost of false positives and invasive tests
3) cost of overdiagnosis - i.e. cost of treatment of people whose cancer wouldn't have caused any problems in their lifetime
4) cost of longer treatment for aggressive cases that are not helped by the treatment other than increase the time after diagnosis (at the expense of time before) (read up on lead-time bias if you don't understand what I am talking about here).
Do you know statistics at least a little bit? Do you understand the difference between relative risk and absolute risk reduction? Do you have a clue about how many people need to be tested for one person to benefit? Do you know that for every person whose life is prolonged, several are treated unnecessarily and may have life shortened as a result?

Do you know that you have a higher chance of being diagnised with some cancers if you are screened? Are you aware that because of false positives and overdiagnosis lots of popular screenings are not even remotely cost-effective because cost of screening+cost of treatment for overdiagnosed cases+ cost of false positives is significantly greater than the savings on less treatment for few?

You can take mammograms as one example and do your math. You can use numbers from this article ( which many consider overly optimistic - the mortality reduction listed in this article is way higher that what USPSTF used and about 4 times more optimistic than more recent Cochrane review (from October this year). If German government is using cost to justify their plans - they are way off. Insurance companies had to be forced to pay for screening because unlike German government they can do their math.

The balance of benefit and harm for most screening tests is not as clear cut as you think it is. Few peolple benefit tremendously from it, but some are hurt. It'd be nice to have some proof of cost effectiveness before you start penalizing people for not doing it.


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