The strange drug/surgery dichotomy

I've dabbled in the realm of health care here before, most notably when I discussed the explosion of the prescription drug industry and its somewhat questionable benefits. I thought it was pertinent, then, to give some mention here to this item from the University of Michigan's Risk Science Blog, which cited a JAMA study that found that many women have undergone unnecessary surgeries in futile attempts to help cure their breast cancer.

It has long been believed that women diagnosed with breast cancer should have “sentinel” lymph nodes near the affected breast checked to see if cancer has spread to them. If cancerous cells were found, standard practice was to have surgery to remove many nodes near the breast and under the arm. This procedure was supposed to help prevent the spread of cancer throughout the body. However, it comes with significant side effects, including infection and lymphedema, a type of chronic and often painful swelling.

In the JAMA study, however, researchers found that some women with early stage breast cancer gained no survival benefit from removal of the lymph nodes even though cancer had been found in the lymphatic system. This finding sparked a wave of publicity, including an insightful Room for Debate feature in the New York Times that included 7 authors’ perspectives on whether American surgeons promote unnecessary surgery.

I have no doubt that many of the issues raised by the New York Times commentators are important. Surgeons do have financial incentives, established practices, and natural responses to clinical uncertainty that lead them to suggest surgery in some cases where there is no clinical evidence to support such an action.

Yet, I think we also need to acknowledge that we, the public, also contribute to overuse of surgical procedures. We do not often complain when our doctor recommends surgery. Many times, in fact, I think patients are relieved when a doctor suggests surgery. We trust that the physical act of cutting out a cancerous tumor, fusing vertebrea in our back, or replacing an aging hip will “fix” our problems. We do not stop to consider whether other approaches might work just as well or better. We do not worry about the fact that someone will cut us open and potentially cause us pain and expose us to significant complication risks.

In the world of drugs, at least, several rounds of famously onerous clinical trials are required before a medication can be brought to market. This process guarantees that a drug has at least displayed some efficacy before it is put into widespread use. But there is no such process for vetting and approving experimental surgical procedures, and patients are therefore given drastically fewer safeguards when the surgical option is proposed.

I'll admit that my ignorance of the health care world makes me unable to go to much farther in my analysis, lest I say (or accuse or criticize) something that is not fully true. But I nevertheless find it unsettling that a relatively cheap and non-invasive procedure like a medication can be subject to a world of regulation, while a much more expensive and invasive surgical procedure can be put into practice nearly on a whim, with little scientific evidence to support it.

I have to wonder if this dynamic is at least in part to blame for our skyrocketing medical costs. How many people have undergone an expensive but unnecessary surgical procedure, taxing our medical community (and the insurance community) for no tangible benefit? It's an almost unanswerable question, especially because it is impossible to decide what is a "necessary" as opposed to an "unnecessary" surgery.

If any of you out there have any insight as to why there is this strange dichotomy between drug approval and surgical procedure approval, I'd be interested to hear more. These are exactly the kinds of questions that must be answered if we are ever to have meaningful health care reform (which, of course, is a much larger question, isn't it?)

[Risk Science Blog]
(h/t Overcoming Bias)