New Study Shows Startling Gap in Cardiovascular Risk Assessment

According to this Wall Street Journal article, doctors are not delving deep enough into family history when assessing their patients' risk of heart disease. This is especially dangerous for women, who  have very different--and sometimes, more subtle--indicators than men.

Seeking Clues to Heart Risk in a Patient's Family Tree

FEBRUARY 21, 2012 

By CHRISTOPHER WEAVER

Doctors often gloss over a key question for assessing a person's risk for coronary heart disease, according to a new study: What is the patient's family history of cardiovascular illness?

The study suggests some doctors may not be capturing the full extent of many patients' chances of developing heart disease. Detailed family information could help doctors better predict who is at risk and more accurately target patients for preventive care that may help avert the disease altogether, according to the study, due to be published Tuesday in the Annals of Internal Medicine. Routinely tracking family history sharply boosted the number of people in the study considered at high risk for heart disease.

A widely used scorecard for measuring heart risk, the Framingham Risk Score, fails to take family history directly into account. And while many doctors currently collect some information about the health of their patients' families, the data often lack the detail to be clinically useful for assessing risk and prescribing care.

"Family history remains one of the most important predictors of an event for an individual," says Donna Arnett, a genetic epidemiologist at the University of Alabama at Birmingham and president-elect of the American Heart Association. Still, "most of the family history that we're collecting is just the presence or the absence of heart disease, not the age of onset or the type of disease," says Dr. Arnett, who wasn't involved in the latest research.

Guidelines for heart-risk screening, issued by the heart association in late 2010, encouraged doctors to take family histories into account. Doctors sometimes make judgment calls to treat people as high risk because of family history, even if it isn't part of the patient's risk score.

The study, funded by the United Kingdom Department of Health, included 748 patients aged 30 to 65. Up to 13% of patients were found to be at high risk of coronary heart disease using traditional assessment tools. After patients filled out enhanced questionnaires that sought more complete information, the percentage considered at high risk jumped to 18%. The traditional assessment could include general information, such as blood pressure, cholesterol level and basic information about whether a family member had a history of heart disease. The enhanced survey would identify, for instance, that a patient's mother had a heart attack at age 50.

"It's a low cost way to target people who are at high risk for cardiovascular disease," says Nadeem Qureshi, the lead researcher and a professor at the University of Nottingham's Faculty of Medicine and Health Sciences in the U.K.

Findings from the U.K.-based study reflect similar use of family history among doctors in the U.S., several U.S.-based physicians say.

Family history has been linked to higher risk for a number of illnesses, including cancer and diabetes. Unlike some other diseases, however, clear genetic markers for coronary heart disease, which accounts for 1 in 6 U.S. deaths, remain elusive. Family histories can be used as a proxy for detailed genetic work that may someday be used to help predict heart-disease risk, researchers say.

Another risk-measurement tool, known as the Reynolds Risk Score, developed by Harvard University researchers in the 1990s, does consider if a patient's parent had a heart attack and at what age. However, many medical practices don't yet use the tool, which became available in 2007.

Using the Reynolds system, the researchers tracked 25,000 initially healthy patients over a decade. They found that a 50-year-old male patient who, among other things, smoked, and had high blood pressure and cholesterol, but no family history of heart disease, had a 12%, or moderate, chance of having a heart attack in the 10-year period. But a similar patient with a parent who had a heart attack before age 60 had a 20% risk, putting that patient at high risk for heart disease. Heart risk wasn't significantly affected in patients with a parent who had a heart attack at the age of 60 or older.

Still, many medical practices continue to rely on the older Framingham Risk Score, which became available in the 1990s. Researchers believed that other factors, including blood pressure and cholesterol levels, provided all the information needed to determine a patient's risk for heart disease.

Doctors use the scoring systems to single out patients who could benefit from counseling about lifestyle changes, such as losing weight and quitting smoking, or from preventive interventions such as low-dose aspirin and cholesterol drugs, says Yul Ejnes, the chairman of the American College of Physicians board of regents. The college publishes the Annals of Internal Medicine.

Primary-care doctors say there are obstacles to gathering family histories from patients, including competing priorities for time in the examination room. And patients often don't know many details about their family members. In the Annals of Internal Medicine study, patients were mailed questionnaires and instructed to gather the material before seeing their doctor.

"It's a little bit of detective work," says Charles Cutler, a primary-care doctor in Norristown, Pa. Patients should make a point of knowing the health histories of their parents, siblings and grandparents, he says. To identify clues about specific diseases, however, Dr. Cutler says he sometimes asks patients questions like: "What do you remember about Grandpop's hospitalization? Were his legs swollen?"

Tamara Barber, a 33-year-old a senior marketing director at a Boston technology firm, says her family history has made her an advocate for her own health. Ms. Barber says she watches her diet and exercises regularly. And although she currently isn't on any heart medication, she regularly pushes her doctor to check thoroughly for signs of developing heart disease.

"I went to the cardiologist and said, 'I may look healthy and my numbers are all good. But my mom had a heart attack when she was 45, and I need to know whether I have any other risk factors that I should be aware of,' " Ms. Barber says.

Write to Christopher Weaver at christopher.weaver@wsj.com


A history of heart disease in the family can have a big impact on your risk of a heart attack. The age when a parent had the attack also affects your risk. Two hypothetical patients:

Patient 1

• Gender: Male
• Age: 55
• Smoking status: No
• Systolic blood pressure: 150 mm/Hg
• Total cholesterol: 300 mg/dL
• HDL (good cholesterol): 30 mg/dL
• Family history: Father had a heart attack at 50 years old
• 10-year risk: 23% (High risk)

Patient 2

• Gender: Male
• Age: 55
• Smoking status: No
• Systolic blood pressure: 150 mm/Hg
• Total cholesterol: 300 mg/dL
• HDL (good cholesterol): 30 mg/dL
• Family history: Father had a heart attack at 70 (too late in life to predict risk)
• 10-year risk: 14% (Moderate risk)

Note: Blood pressure of 140 mm/Hg or above is considered high. Total cholesterol typically ranges from 100 to 400 mg/dL; optimal level is below 160 mg/dL. Ten-year heart-attack risk of 20% or greater is high; moderate risk is 10% to 19%. Source: Reynolds Risk Score

Too Much of a Good Thing...

Doctor exposes the dangers of overtreatment

By Liz Szabo, USA TODAY

ATLANTA – The woman walked quietly into the busy emergency room at Grady Memorial Hospital, Atlanta's safety net hospital for the poor and uninsured. She waited four or five hours to be seen, sitting patiently on a gurney and clutching a plastic bag.

Inside the bag was a moist blue towel. Wrapped inside that towel was her right breast. She was hoping it could be reattached.

Doctors in the United States don't see cancer patients like this every day. A mixture of fear, poverty and lack of paid sick leave had led her to delay cancer treatment for years. Eventually, the tumor grew so large that it cut off the blood supply, causing her right breast to die and fall off, says Otis Brawley, chief medical officer at the American Cancer Society, who saw the woman in the ER that morning in 2003.

• MORE: Excerpt from 'How We Do Harm:' Chapter 10

In his new book, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America, Brawley presents the woman's suffering as a metaphor for a rotting health system that is run, he says, "by the greedy serving the gluttonous."

How much is too much?

Americans often assume that more is better. But supersizing your healthcare -- by getting tests and procedures that you don't really need and which aren't based on sound science -- can kill you, according to a revealing new book by the American Cancer Society's chief medical officer, Otis Brawley.

• Many tests, treatments not necessary Many patients would be surprised to realize how little of the medicine they receive is actually backed by evidence.
• Doctors say he has duty to tell the truth Otis Brawley says he’s not worried about being called a radical.
• Twitter chat with Otis Brawley Chat with Brawley of ACS at 2 p.m. ET Wed. about his new book on overtreatment

A nation of extremes

Brawley uses the book, on sale today (St. Martin's Press, $25.99) and co-written with journalist Paul Goldberg, to show that ours is a nation of extremes, with the poor or uninsured frequently denied even the most basic care while the well-insured often are "overtreated," receiving unproven drugs and procedures that can cause real harm.

"Our medical system fails to provide care when care is needed, and fails to stop expensive, often unnecessary and frequently harmful interventions, even in situations when science proves those interventions are the wrong thing to do," Brawley writes. Too many patients, Brawley writes, get a "wallet biopsy" that decides whether they'll get care. Patients without money or insurance often get no care until they're "sick enough or old enough for government benefits to kick in." Then, patients are welcomed back into the system, "because even at Medicare and Medicaid coverage rates, you can make money on uncontrolled diabetes, kidney failure, heart disease and late-stage cancer.… "

On the other end, he writes, "wealth in America is no protection from getting lousy care.… Wealth can increase your risk of getting lousy care. If you have more money, doctors sell you more of what they sell, and they just might kill you."

Brawley says he doesn't want to ration care or dash the hopes of desperate patients who are willing to gamble on experimental therapies. But he says he's tired of those hopes being exploited by a medical system that's too lazy to insist that care be based on science rather than profit or best guesses.

Patient advocates such as Fran Visco, a breast cancer survivor, welcome Brawley's call to action. "We pour so much money into overtreatment," says Visco, president of the National Breast Cancer Coalition. "All of that could be channeled into getting more people care."

Brawley's message may resonate with policymakers because of his high rank within the cancer society, says Dartmouth Medical School professor Lisa Schwartz, who co-wrote a book last year called Overdiagnosed: Making People Sick in the Pursuit of Health. Brawley's folksy style and sense of humor — his take on medicine is often darkly funny — makes complex issues easy for the public to understand, says Barry Kramer, director of cancer prevention at the National Cancer Institute.

Brawley fills the book with the stories of patients no longer here to speak for themselves.

Consider the woman who died after being given massive doses of an unnecessary but highly profitable anemia-fighting drug that could, studies later showed, sometimes "act like Miracle-Gro for cancer," Brawley says. There's the prostate cancer patient who "died from the cure," after overaggressive treatment of a slow-growing tumor that probably didn't need to be found. And there's the dying lung-cancer patient — responsive only to pain — whose family insists that Brawley, then a young resident, perform one futile invasive procedure after another.

"I'm quite sure Otis remembers the patients who didn't do well, more than the patients who did, because that's the kind of caring individual he is," says Michael Friedman, director of City of Hope cancer center in Duarte, Calif. "It's not that Otis has all the answers, but he's asking all the right questions."

Striding through the halls of Grady Hospital today, Brawley says it was built during the days of segregation, a "monument to racism," to keep black and white patients separate. The health care system today is just as badly designed. "Too often, helping the patient isn't the point," Brawley writes. Perverse economic incentives "can dictate the patient be ground up as expensively as possible with the goal of maximizing the cut of every practitioner who gets involved."

Some point out that doctors aren't deliberately trying to harm their patients.

But doctors may not question the system, either, says Thomas Smith, director of palliative care at Johns Hopkins Medical Institutions in Baltimore. "Most doctors are sleepwalkers, not evildoers," Smith says.

"A lot of people are trying to do their best in a broken system," Schwartz says, adding that it's too simple to say it's all about greed. "It's about how hard it is to come up with a system that gives people what they need."

Making the best decision about care — such as when to provide hospice care, for example, rather than more invasive procedures — can be complicated and doesn't necessarily reflect a doctor's desire to make money, says Smith.

Smith agrees with Brawley that changing the system will require educating patients and families. "This can't come just from doctors and nurses. It will require some changes in society and people, to accept the medical facts," Smith says.

Patients affect care, too

Brawley notes that patients themselves often ask for unproven treatments, even demanding that insurers pay for them. In many cases, however, those extra tests and treatments aren't in patients' best interests. "Prostate-cancer screening and aggressive treatment may save lives," Brawley writes, "but it definitely sells adult diapers."

Standing at the window of Grady's tenth-floor cancer center, in his white doctor's coat, Brawley points out Ebenezer Baptist Church, where Martin Luther King once preached, and the building where the Southern Christian Leadership Conference met. "This is the cradle of the civil rights movement," Brawley says.

And like the civil rights movement, change will have to come from the bottom up, Brawley says, and from patients who have had enough.

"The health care system is dramatically broken," Brawley says. "All of us need to radically change. I'm convinced that health care transformation is a civil rights issue."

Brawley has broken ranks with his peers before, often by saying things on the record — clearly, and in colorful language — that others acknowledge only in private.

While his supervisors at the cancer society have always supported him — Brawley says he was a "known commodity" when hired in 2007 — his unvarnished assessments of cancer drugs and screening tests have often gotten him in hot water with patient advocates, and even cancer society members. While Brawley recommends mammograms, he says doctors should be honest with women about their limitations and risks: "There is this pervasive belief," he says, "that mammography is better than it is."

Prostate cancer advocate Tom Kirk is familiar with Brawley's arguments, and his rhetorical flourishes. "There are a great number of us who have learned to engage with Otis, and it is rare that he says something about prostate cancer where there isn't a chorus of us who respond," says Kirk, president and chief executive officer of the group Us TOO. While Kirk says he appreciates Brawley's efforts to get men to think carefully about health care decisions, he also fears that men could use Brawley's words as an excuse to avoid doctors entirely. Men "have come too far in this country not to play an active role in our health care," Kirk says.

Brawley praises other patient-led efforts, such as the National Breast Cancer Coalition's Project LEAD. The free training program teaches patients and their supporters to understand medical evidence, and advocate for treatments and policies that reflect the best science.

Consumers typically misinterpret any attempt to limit care as a cost-saving scheme, Schwartz says. "Even if we had all the money in the world," Schwartz says, "we would still want to make better decisions about how to make people feel better and live longer."

Some of Brawley's concerns are already being addressed, says John McDonough, a professor at the Harvard School of Public Health.

Beginning next year, Medicare will penalize facilities where patients get a lot of hospital-acquired infections, and where a lot of patients are readmitted shortly after being discharged, McDonough says.

The Affordable Care Act, the healthcare law championed by the Obama administration, also provided funding for a research center that compares existing treatments against each other, something that's not ordinarily done when new drugs are approved, McDonough says.

The Affordable Care Act also creates community groups, called accountable care organizations, through which hospitals can work with local groups to improve community health, says Gerard Anderson, of the Johns Hopkins School of Public Health.

But McDonough also says it's not possible to make the system work perfectly. "The notion that there is a pure, rational way to do something, on which everyone could agree, just doesn't fit reality," McDonough says.

And Anderson says that even the most educated and empowered patients may still have trouble challenging their doctors.

"When your doctor says, 'You need this procedure,' it's really hard to say, 'Really? I don't think I need that,' " Anderson says.

"We just don't have enough information as consumers."

Community Outreach is the Key to Overcoming Healthcare Disparities

Studies like this, while disturbing, can serve as a great motivator. Healthcare providers must step up grassroots efforts to educate at-risk communities on the importance of cancer screening.

CDC Press Release: Study finds racial and ethnic disparities in US cancer screening rate

Study finds racial and ethnic disparities in US cancer screening rates
Screening rates lower among Asian and Hispanic Americans
The percentage of U.S. citizens screened for cancer remains below national targets, with significant disparities among racial and ethnic populations, according to the first federal study to identify cancer screening disparities among Asian and Hispanic groups. The report by the Centers for Disease Control and Prevention<http://www.cdc.gov> and the National Cancer Institute (NCI), part of the National Institutes of Health, was published today in the CDC Morbidity and Mortality Weekly Report<http://www.cdc.gov/mmwr>.

In 2010, breast cancer screening rates were 72.4 percent, below the Healthy People 2020 target of 81 percent; cervical cancer screening was 83 percent, below the target of 93 percent; and colorectal cancer screening was 58.6 percent, below the target of 70.5 percent, according to the study, "Cancer Screening in the United States - 2010."