The Latest Screening Recommendations

The past few years two more ill conceived screening programs have been foisted upon primary care providers. The current recommendation is that smokers over the age of 50 be screened for lung cancer with a low dose CT scan of the chest annually. This program came from a single flawed American study that compared screening with CT against screening with chest X -ray; but we have known for decades that the latter does not work because chest X -ray picks up too many incidental findings (“incidentalomas”) that lead to unnecessary invasive intervention and death, so overall mortality does not decrease. The American CT study showed a 20% decrease in lung cancer death but only a 6.7% decrease in overall mortality. If it had been compared to no screening instead of screening with chest X -ray it probably would have shown no decrease in overall mortality; we know this because similar studies in Europe have shown no benefit to CT screening. Fortunately, the American Academy of Family Practice Physicians (AAFP) finally put its foot down in 2014 saying that this recommendation was ill-founded, so most family physicians do not screen for lung cancer.

Recently Pennsylvania passed a bizarre law mandating that physicians offer baby boomers (those born between 1945 and 1965) screening blood work for Hepatitis C. Why mandate this screening and no other? Because of Gilead. Gilead is the drug company that developed Sovaldi and Harvoni, drugs that are touted as cures for various strains of Hepatitis C. You can follow the exploits of Gilead’s lobbying campaign on Bloomberg News and other media outlets because they are so unusual and so successful. As yet we do not know if these drugs actually cure the disease or just hold it in remission for a time (like HIV) because there are no long term studies. But let us assume we have a cureGilead is charging $90,000 for the cure. Most of those who are eligible for the cure are IV drug abusers. Recognizing that most people, governments, and insurance companies would balk at this price to\ save the lives of IV drug abusers, Gilead has contributed literally hundreds of millions to patient advocacy organizations and to lawsuits launched by such organizations on the part of the poor trying to force Medicaid and insurance companies to pay for their overpriced drugs. Like all other drug companies, Gilead also engages in conventional lobbying of legislators at both the national and state levels, hence a law forcing physicians to screen for Hepatitis C. The drug companies make more profit than any other sector of the economy, so there is lots of money for our politicians. Prior to the passing of this law most primary care providers resisted the recommendation to screen for Hepatitis C, a situation that Gilead found intolerable. After all, why not wait until a patient becomes symptomatic. Gilead argues that some patients will die of cirrhosis or liver cancer if you wait for symptoms to appear, which is true. But only about 9000 people die each year of Hepatitis C, and the vast majority present with symptoms that allow treatment before the consequences become irreversible. Could the huge amount of money required for Hepatitis C screening be better spent elsewhere? I will discuss this issue next month.

– Gary Gallo, MD