Wednesday, March 11, 2009

The Science of Being Worried Sick

One of my bugaboos, ever since I learned there was a name for it, is iatrogenic risks: the damage that medicine itself can cause, however inadvertently. A big ole iatrogenic risk made the news recently, as Ivanhoe's medical news wire service reports:
The agonizing wait for breast cancer biopsy results can be harmful to a woman's health. The results of a new study suggests not knowing a diagnosis can lead to stress that may have adverse effects on the immune system.

More than 1.2 million breast biopsies are performed each year in the U.S. -- 80 percent result in non-cancerous findings. In this new study, researchers sought to establish a biochemical marker to assess the physical effects associated with the stress of extended waiting for a final diagnosis. They collected stress hormone [cortisol] samples from 126 women who had just undergone a large core biopsy. Four days later, the scientists learned the stress hormone levels of women with uncertain results were significantly different than women with benign results, but highly similar to women with malignant results.

(The original study is published in Radiology, March 2009, full reference below.)
Any of you who've awaited the results of high-stakes medical tests are probably thinking: Well, duh! The day I got my initial, troubling MRI results, I was in tears for much of the day before I even saw my doctor. I'm pretty sure my cortisol levels stayed sky-high for a several weeks, until I heard that I didn't have MS and that the radiologist who read the scans was probably mostly covering his ass.

So why is there any value in a study like this one? Because even though its findings are glaringly obvious, it points out that most of the women in the study had to wait at least five days for results. The study's authors, Elvira Lang et al., recommend in another well, duh! moment:
It is important to deliver histopathologic results in a timely fashion.

(Source: Elvira V. Lang et al., "Large-Core Breast Biopsy: Abnormal Salivary Cortisol Profiles Associated with Uncertainty of Diagnosis," Radiology 2009;250:631-637.)
Or to put it bluntly, doctors and hospitals need to organize anxiety-producing procedures with the patient's needs in mind, not the organization's. This would be worthwhile even if stress weren't a risk factor for (additional) illness.

By the way, it's not just women who would benefit from faster, healthier, and more humane delivery of test results. Lang et al. cite a larger, better-powered study in which men who underwent prostate biopsy had the most abnormal cortisol levels two weeks after the biopsy, right before they got their results. Like breast biopsies, prostate biopsies are more painful than doctors will generally admit, or so I hear from people who've experienced one or the other procedure. A cancer diagnosis in either case often strikes at a person's identity and sexuality as well as raising fears of mortality. Lang et al. write (again in the full text version):
These authors reported that some of their patients described the waiting period as a nightmare.
That earlier study was published in 1995, and yet people often still wait a week for test results. I'm hoping the new study might make a bigger splash, as breast cancer news tends to attract more media attention.

How long is the waiting period, exactly, before an obvious iatrogenic risk can be diagnosed and treated?


DaisyDeadhead said...

As you might imagine, hear about this stuff everyday. Lots of people who use natural products and supplements have been scared out of conventional medicine, and they tell me the stories. (Then I'm afraid to go to doctors, too.)

Drugs with side effects, leading to more drugs, with more side effects, seems to be the major story.

Sungold said...

Yeah, fear isn't such a hot way to make medical decisions - or any decisions, really. There are lots of things that medicine screws up, and even more areas where it's imperfect simply because we are complex creatures. Drug side effects fall mostly in that second category, even though there are plenty of examples of drug companies bending and breaking the rules, and doctors not keeping track of their patients' various prescriptions.

I'm not willing to abandon conventional medicine, though. I just want it to become more responsive and address obvious, known problems.

Hydraargyrum said...

I have become so cynical about the medical-industrial complex and am not beyond using the term iatrogenicide. One of my major criticisms of physicians is their tendency to prescribe (anti-)depressents like smarties, wreck people neurochemically then prescribe a gazillion other substances to deal with the side effects. What sort of healthcare is that?

Sungold said...

You are making me miss the European version of Smarties! Chocolate is *always* superior.

I know that I have readers here whose lives have been restored to them, thanks to anti-depressants. I also know of others who've been given anti-depressants for situational reasons, as a quick fix, where talk therapy and practical support would have been more appropriate. Used in that way, anti-depressants can function like religion did in the Middle Ages, accommodating people to a bad situation instead of helping them *change* the situation.

hesperia said...

I've walked alongside many family members and friends waiting for serious diagnoses - too many. Even those who got terrible news experienced relief to finally discover what they were dealing with and many describe the waiting period as the worst part of the process. The medical community often has to have things proven to them that human beings have known intuitively for a long time. Whatever it takes, I guess. But perhaps they could be responsive to patient's emotions in a more timely way if they simply talked to them.

Hydraargyrum said...

I accept that there are times where the prescription of anxiolytics or antidepressants are perfectly reasonable and can really help people get their lives back. However, there are also plenty of situations where physicians have prescribed anxiolytics for the shallowest of reasons and individuals have ended-up in a cycle of dependency that can quite literally wreck them.

I, too, miss Smarties as they are in Europe. I will attempt to traffic some on my next trip to la belle Ecosse.

Sungold said...

Hesperia - That prostate biopsy study I mentioned had one other interesting finding: two weeks after the men got their results, cortisol levels were virtually identical between the group that got good news and those who got a cancer diagnosis. That seems counterintuitive to me, but it's true that once the uncertainty is eliminated, you can at least start to make plans and plot strategy.

Hydraargyrum - I think we're on the same page. The problem is that medical decision-making doesn't always take the long term into account, and prescribing pills can appear cheaper/easier/more effective in the short run. Make sure you bring me back some Smarties if you happen to get your hands on some.

hesperia said...

I suspect that we feel completely out of control in the waiting period and when we're given the information, even if it's bad news, we feel that there are things we can do. Even if all we can do is arrange our lives to deal with catastrophe, it seems to be better than sitting around just waiting for the axe to fall.

Sungold said...

Yep. We seem to feel better as long as we have at least an illusion of some control - and can take action.