Recently, consumer articles heralded that blood tests for detecting Alzheimer’s dementia (AD) and many cancers were close to clinical availability. Given the narrow window in which AD must be diagnosed for present treatments to be effective, and questions regarding the utility of early cancer detection, will these tests provide any patient advantage?
Presently, there are two medications to treat AD. Neither is curative, but they slow disease progress by about five months. Despite guidelines that geriatric patients receive cognitive assessments annually, reimbursed by Medicare, few physicians administer them, and approximately 92 percent of individuals, mostly of color, within the initial stage remain undiagnosed. Even if a greater number were detected earlier, only 10 to 12 percent would qualify for the drugs because of comorbidities, other medications they use, and additional factors.
Is a five-month delay in progression worth a treatment involving patient discomfort, multiple ancillary assessments, and potentially fatal side effects? Especially as the FDA is reconsidering one of the two drugs because of side effect lethality, and as the Health Research Group noted, these drugs “have shown no or only minimal clinical benefit.” These medications, with their additional testing, are expensive, and wide use would increase costs for everyone, whether on Medicare or paying the Medicare tax.
The cancer test will identify several cancer types but is not anticipated to be a routine test. Instead, it is expected to be used only if a patient exhibits indicators that usually do not arise in a tumor’s earliest stages, making it unclear whether the test will increase early detection and treatment. There is also concern that low-risk cancers that do not necessitate any or intensive treatment will be overidentified. Will patients be satisfied with having an untreated neoplasm, or will it result in anxiety and depression, as cancer is the major fear of approximately 40 percent of adults? And will they demand (unnecessary) therapy?
Additional testing would be required if the blood test is positive. What if secondary testing indicates that the screening test was a false positive? Would further interval testing (i.e., every six or twelve months) be recommended, for caution, and if so, for how long? How will knowing that assessment will be indeterminate affect one’s emotions? And, as there may be many individuals with repetitive tests, how costly would this be?
The situation is not as bleak as it appears, as we are not powerless in relation to these conditions. There are actions an individual can take that show a similar delay in AD progression and in possible cancer prevention. These are readily available for most people, in many instances at low cost. We hear or read about these daily in relation to AD, cancer, and numerous other conditions, as the advice is essentially the same for all: healthy eating; weight loss; adequate exercise; avoiding tobacco products, addictive drugs, alcohol; etc.
The existing data, even when accurate, can be confusing because of contradictory statements. We are told that green leafy vegetables are healthy and should be consumed regularly. Yet simultaneously we are advised that these foods should be avoided because of bacterial contamination, insecticides, or heavy metals. Ideally, these ambiguities should be reconciled or explained in patient information.
Total abstemiousness can be self-defeating as it causes stress and is boring. When I worked with obese clients with comorbidities, referred by their physicians, I advocated general adherence and moderation as they are more rewarding and reinforce continuance. As with most things, people make choices. I exercise minimally, have an occasional weak alcoholic drink, an infrequent rich meal, and a rare small cigar (without inhaling), all with my geriatrician’s approval. Unfortunately, too many of us prefer total non-adherence, which is easier and more fun, though deleterious over time. As a country, we recently reached an undesirable benchmark, with over 40 percent of adults and slightly under 20 percent of youth being obese or very obese, and the effects are detrimental personally and costly.
There are also disease influences, which, given their ubiquity, we as individuals have little to no control over: heavy metals, microplastics, and forever chemicals. These are a special bane for the poor and people of color, but everyone is affected. To change their commonality requires community effort and political influence, as the companies that produce these and other toxins wield great influence on state and federal legislators.
But for those factors over which we have control, we should exert discipline. My first instruction to those I aided was to ignore the advice and goals given and choose small goals—targets one can master easily. Too frequently, people set overly ambitious targets (i.e., New Year’s resolutions), dooming themselves to failure. Think of your weight loss, for example, in five-pound increments, and exercise in the same manner. By doing this, each small goal is a win that energizes one to go further. With these techniques, all of my referred clients lost significant weight and improved their health status.
For too many of us, a medical crisis is necessary for change rather than advice when we feel well. The former may result in death or disability, either of which can hinder return to a quality life, making change before a catastrophe preferable.
M. Bennet Broner is a medical ethicist.
