검진 뉴스. EndoTODAY 이준행

[건진 관련 해외 언론보도]

1. New York Times

New York Times의 Health section은 제가 후배 의사들에게 권하는 훌륭한 사이트입니다. 비판적 입장을 유지할 수 있다면 정말 많은 것을 배울 수 있습니다.

미국 의료로부터 뭔가를 참고할 때에는 무척 주의해야 합니다. 잘 못 배우면 차라리 안 배운 것 보다 못하기 때문입니다 (예는 무척 많습니다). 미국인의 사고방식은 우리와는 너무나 다릅니다. 언론이 건강문제를 다루는 방식은 더욱 다릅니다. Cancer screening에 대한 New York Times의 기사들을 읽어보면 그 차이가 금방 느껴집니다. 우리나라에는 '어떠어떠한 검사를 받고 건강 장수 이룩하자'라는 선정성 기사가 많습니다. NY Times에는 '정말 그 검사가 필요한가요? 도움이 된다는 증거는 있습니까?'라는 논조의 글이 자주 실립니다.

Controversies over mammograms라는 제목의 2009년 11월 29일자 New York Times 기사 일부를 옮깁니다. Mammogram이 pseudodisease를 너무 많이 발견하고 있다는 주장입니다. Overdiagnosis 이슈입니다.

"Screening turns up lots of tiny abnormalities that are either not cancer or are slow-growing cancers that would never progress to the point of killing a woman and might not even become known to her. If a suspicious abnormality is found, women usually get another mammogram or imaging test to better identify it and often a biopsy to determine if it is cancerous. If it is, most women have it treated with surgery, radiation, hormone therapy or chemotherapy, all of which carry risks for the patient.

The scientific argument is that it is not worth taking such risks for the large number of women whose cancers grow too slowly to kill them. But it is difficult, in practice, to apply that kind of scientific analysis to the immediate questions confronting a woman and her doctor when a mammogram turns up an abnormality. The only real solution will come when researchers find a way to distinguish the dangerous, aggressive tumors that need to be excised from the more languorous ones that do not."

Prostate cancer screening에 대한 NY Times의 토론방을 방문해 보는 것도 흥미로울 것 같습니다. 의학전문기자 Gina Kolata의 여러 글도 읽어 보십시오. 바쁘시면 제목이라도 읽어보십시오. 느낌이 확 옵니다.

우리나라 언론에서 건강에 대한 주제를 다루는 방식은 바뀌어야 합니다.

2. Health screening is too political

어제에 이어 New York Times의 기사를 하나 더 소개합니다. 의학전문기자 Gina Kolata의 "Cancer Group Has Concerns On Screenings"라는 제목의 글입니다.

크게 보실 분은 여기를 누르십시오.
전문을 PDF로 보실 분은 여기를 누르십시오.

이런 말이 나옵니다. 'Politically, it's almost unacceptable,'' Dr. Albertsen said. 'If you question overdiagnosis in breast cancer, you are against women. If you question overdiagnosis in prostate cancer, you are against men.'

암검진은 너무 정치적 의미가 강하므로 사실 어떻게 하기 어려운 주제입니다. Albertsen 박사의 말처럼 유방암 검진에 대하여 의문을 제기하면 여성의 표를 잃게 될 것입니다. 남성의 표를 얻기 위해서 전립선암 검진이 필요하다고 주장할 수도 있습니다. 한번 시작한 검진대상을 축소하는 것은 거의 불가능한 일입니다. 이래저래 암검진은 evidence-based medicine을 적용하기 어렵습니다. 너무 정치적 색이 진합니다. Health issue 보다는 political issue가 되버렸습니다. 안타까운 일입니다.

힘없는 저로서는 국민 건강이 걱정될 뿐입니다.

3. New York Times Health section 기사 스크랩

암에 대한 개념이 바뀌고 있습니다. 암에 걸리면 무조건 죽는 것이고, 이를 막기 위해서 조기진단이 최선이라는 생각. 너무나 당연한 상식같지만 꼭 옳은 것은 아닙니다. 암진단 후 적절히 치료하면 장기생존이 가능한 예가 얼마든지 있습니다. 조기진단을 위한 지나친 screening의 해악도 무시할 수 없습니다. 무슨 이유인지 국내에서는 잘 논의되지 않고 있습니다. 그러나 New York Times에서는 적어도 1주일에 한번 이에 대한 기사가 실립니다. 누구의 관점이 옳은 것일까? 최근 기사를 일부 모아보았습니다.

[2011-10-3. New York Times] How to Steer Toward the Path of Least Treatment (link2)-"I think we don’t talk with patients enough about the fact that there is an optimum amount of medical care, and when you start giving too much, there’s definitely a risk that it’s going to be harmful" -- 논문 link

[2011-10-7. New York Times] Panel's advice on prostate test sets up battle (link2) -- 미국 정부에서는 건강한 사람의 검진 목적으로 PSA 혈액검사를 하지 말라고 권하고 있다. 우리나라에서는 생각도 할 수 없는 일이다.

[주인장의 선택] [2011-10-10. New York Times] Screening is gambling (link2)

[2011-10-13. New York Times] Cancer risk from Barrett's esophagus lower than thought

[2011-10-20. New York Times] When doing nothing is the best medicine (link2)

[2011-10-25. New York Times] Mammogram’s Role as Savior Is Tested (link2) - Even with screening, the bad cancers are still bad

[2011-10-29. New York Times] Considering When It Might Be Best Not to Know About Cancer (link2)

[2011-10-31. New York Times] Small tumors can be vicious, big ones innocuous. (link2) - Steve Jobs가 수술을 늦춘 것이 꼭 나쁜 결정은 아니었을 수도 있다. 일찍 수술했더라도 상황이 달라지지 않았을 수 있다.

[2011-11-7. New York Times] Carotid artery bypass surgery의 효과에 의문

[2011-11-14. New York Times] Active surveillance for prostate cancer

[2011-12-3. New York Times] 'Cancer' or 'Weird Cells': Which Sounds Deadlier?

[2011-12-3. New York Times] Health Official Takes Parting Shot at ‘Waste’

[주인장의 선택] [2012-2-27. New York Times] If You Feel O.K., Maybe You Are O.K.

4. Overdiagnosis and Overtreatment in Cancer (JAMA 2013-7)

Screening이 활발한 시대의 과잉치료에 대한 문제제기입니다. 문제 해결을 위한 몇 가지 방안이 설득력있게 제시되어 있습니다. 아래는 그 중 하나입니다. Indolent disease 진단을 줄이는 방법은 무엇일까요? 바로 효과가 낮은 검사를 줄이는 것입니다. 진단한 후 고민하기 보다는 진단하지 않는 것이 더 좋은 병도 있습니다. 모르는게 약이라는 말도 있지 않습니까?

Mitigate overdiagnosis. Strategies to reduce detection of indolent disease include reducing low-yield diagnostic evaluations appropriately, reducing frequency of screening examinations, focusing screening on high-risk populations, raising thresholds for recall and biopsy, and testing the safety and efficacy of risk-based screening approaches to improve selection of patients for cancer screening. The ultimate goal is to preferentially detect consequential cancer while avoiding detection of inconsequential disease.

5. [2013-8-1. New York Times] Scientists Seek to Rein In Diagnoses of Cancer

A group of experts advising the nation’s premier cancer research institution has recommended changing the definition of cancer and eliminating the word from some common diagnoses as part of sweeping changes in the nation’s approach to cancer detection and treatment.

The recommendations, from a working group of the National Cancer Institute, were published on Monday in The Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.
The group, which includes some of the top scientists in cancer research, also suggested that many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should instead be reclassified as IDLE conditions, which stands for “indolent lesions of epithelial origin.”
While it is clear that some or all of the changes may not happen for years, if it all, and that some cancer experts will profoundly disagree with the group’s views, the report from such a prominent group of scientists who have the backing of the National Cancer Institute brings the discussion to a higher level and will most likely change the national conversation about cancer, its definition, its treatment and future research.
“We need a 21st-century definition of cancer instead of a 19th-century definition of cancer, which is what we’ve been using,” said Dr. Otis W. Brawley, the chief medical officer for the American Cancer Society, who was not directly involved in the report.
The impetus behind the call for change is a growing concern among doctors, scientists and patient advocates that hundreds of thousands of men and women are undergoing needless and sometimes disfiguring and harmful treatments for premalignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.
The advent of highly sensitive screening technology in recent years has increased the likelihood of finding these so-called incidentalomas ? the name given to incidental findings detected during medical scans that most likely would never cause a problem. However, once doctors and patients are aware a lesion exists, they typically feel compelled to biopsy, treat and remove it, often at great physical and psychological pain and risk to the patient. The issue is often referred to as overdiagnosis, and the resulting unnecessary procedures to which patients are subjected are called overtreatment.
Cancer researchers warned about the risk of overdiagnosis and overtreatment as a result of new recommendations from a government panel that heavy smokers be given an annual CT scan. While the policy change, announced on Monday but not yet made final, has the potential to save 20,000 lives a year, some doctors warned about the cumulative radiation risk of repeat scans as well as worries that broader use of the scans will lead to more risky and invasive medical procedures.
Officials at the National Cancer Institute say overdiagnosis is a major public health concern and a priority of the agency. “We’re still having trouble convincing people that the things that get found as a consequence of mammography and P.S.A. testing and other screening devices are not always malignancies in the classical sense that will kill you,” said Dr. Harold E. Varmus, the Nobel Prize-winning director of the National Cancer Institute. “Just as the general public is catching up to this idea, there are scientists who are catching up, too.”
An expert panel says lesions found in some cancer screenings should not be called cancer but should instead be reclassified.
An expert panel says lesions found in some cancer screenings should not be called cancer but should instead be reclassified. One way to address the issue is to change the language used to describe lesions found through screening, said Dr. Laura J. Esserman, the lead author of the report in The Journal of the American Medical Association and the director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco. In the report, Dr. Esserman and her colleagues said they would like to see a multidisciplinary panel convened to address the issue, led by pathologists, with input from surgeons, oncologists and radiologists, among others.
"Ductal carcinoma in situ is not cancer, so why are we calling it cancer?" said Dr. Esserman, who is a professor of surgery and radiology at the University of California, San Francisco.
Such proposals will not be universally embraced. Dr. Larry Norton, the medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering Cancer Center, said the larger problem is that doctors cannot tell patients with certainty which cancers will not progress and which cancers will kill them, and changing terminology does not solve that problem.
“Which cases of D.C.I.S. will turn into an aggressive cancer and which ones won’t?” he said, referring to ductal carcinoma in situ. “I wish we knew that. We don’t have very accurate ways of looking at tissue and looking at tumors under the microscope and knowing with great certainty that it is a slow-growing cancer.”
Dr. Norton, who was not part of the report, agreed that doctors do need to focus on better communication with patients about precancerous and cancerous conditions. He said he often tells patients that even though ductal carcinoma in situ may look like cancer, it will not necessarily act like cancer ? just as someone who is “dressed like a criminal” is not actually a criminal until that person breaks the law.
“The terminology is just a descriptive term, and there’s no question that has to be explained,” Dr. Norton said. “But you can’t go back and change hundreds of years of literature by suddenly changing terminology.”
But proponents of downgrading cancerous conditions with a simple name change say there is precedent for doing so. The report’s authors note that in 1998, the World Health Organization changed the name of an early-stage urinary tract tumor, removing the word “carcinoma” and calling it “papillary urothelial neoplasia of low malignant potential.” When a common Pap smear finding called “cervical intraepithelial neoplasia” was reclassified as a low-grade lesion rather than a malignancy, women were more willing to submit to observation rather than demanding treatment, Dr. Esserman said.
“Changing the language we use to diagnose various lesions is essential to give patients confidence that they don’t have to aggressively treat every finding in a scan,” she said. “The problem for the public is you hear the word cancer, and you think you will die unless you get treated. We should reserve this term, ‘cancer,’ for those things that are highly likely to cause a problem.”
The concern, however, is that since doctors do not yet have a clear way to tell the difference between benign or slow-growing tumors and aggressive diseases with many of these conditions, they treat everything as if it might become aggressive. As a result, doctors are finding and treating scores of seemingly precancerous lesions and early-stage cancers ? like ductal carcinoma in situ, a condition called Barrett’s esophagus, small thyroid tumors and early prostate cancer.
But even after years of aggressively treating those conditions, there has not been a commensurate reduction in invasive cancer, suggesting that overdiagnosis and overtreatment are occurring on a large scale.
The National Cancer Institute working group also called for a greater focus on research to identify both benign and slow-growing tumors and aggressive diseases, including the creation of patient registries to learn more about lesions that appear unlikely to become cancer.
Some of that research is already under way at the National Cancer Institute. Since becoming director of the institute three years ago, Dr. Varmus has set up a list of “provocative questions” aimed at encouraging scientists to focus on critical areas, including the issue of overdiagnosis and molecular tests to distinguish between slow-growing and aggressive tumors.
Another National Cancer Institute program, the Barrett’s Esophagus Translational Research Network, or Betrnet, is focused on changes in the esophageal lining that for years have been viewed as a precursor to esophageal cancer. Although patients with Barrett’s are regularly screened and sometimes treated by burning off the esophageal lining, data now increasingly suggest that most of the time, Barrett’s is benign and probably does not need to be treated at all. Researchers from various academic centers are now working together and pooling tissue samples to spur research that will determine when Barrett’s is most likely to become cancerous.
“Our investigators are not just looking for ways to detect cancer early, they are thinking about this question of when you find a cancer, what are the factors that might determine how aggressively it will behave,” Dr. Varmus said. “This is a long way from the thinking 20 years ago, when you found a cancer cell and felt you had a tremendous risk of dying.”

[References]

1) EndoTODAY 건진 내시경

2) 청년의사. 강명신의 New York Times 읽기

3) Minsoo Jung. National Cancer Screening Programs and Evidence-Based Healthcare Policy in South Korea. Health Policy (2014)