Friday, September 02, 2005

Disease Mongering-One more obstacle in the search for medical knowledge?

Recently, the American Diabetes Association (ADA) issued a statement casting doubt on the validity and usefulness of the concept of metabolic syndrome and suggesting that physicians not make that diagnosis. One of the news articles about this statement used the term disease mongering.I had not previously been aware of that term. Mongering has two dictionary definitions:
1) to deal in a commodity 2) to promote something undesirable or discreditable. A 2002 BMJ article deals with disease mongering which describe as follows: " Some forms of "medicalization" may now be better described as " disease mongering"- extending the boundaries of treatable illness to expand markets for new products.
A 1992 book entitled "Disease-Mongers" by Lynn Payer, health editor of the New York Times, provides an early application of that characterization.Two years earlier, Ivan Illich's often quoted "Limits to Medicine" had dealt in part with that subject.
The BMJ article speaks of disease awareness campaigns that are linked to companies' marketing strategies and company sponsored advisory boards, risk conceptualized as diseases and disease prevalence estimates constructed to maximize the impact and importance of a given medical issue.
Osteoporosis was given as a example of a risk conceptualized as a disease. A diagnosis of osteoporosis can be made on the basis of a bone mineral density (BMD) test if the patients' test results vary sufficiently from that of a normal young woman. BMD is one of the risk factors for osteoporotic fractures but in this formulation a low BMD becomes a disease worthy of ICD coding, prescription medication and continuing followup with more BMD determinations. The authors reference the role of drug companies in sponsoring meetings where the disease was defined, and funded studies of therapies and patient groups and and disease foundations.There has definitely been a paradigm shift, patients at some higher level of risk for fracture have been defined as having osteoporosis and there is widespread knowledge of the test, the new definition and patient acceptance of prescription medication.
All of this has to give a physician some cause for concern. Have we been bamboozeled by Big Pharma, have patients and physicians been sold a bill of goods? The authors would say yes, but I do not believe it is that simple. Trying to disentangle the facts from drug company hype and spin in a literature so often highly influenced by those drug companies is no easy task.
The treatment of osteoporosis has a sound foundation. 25 years ago we had no treatment for the painful complications of osteoprosis, we do now. That is not the issue. The issue is are we preemptively " treating" a low BMW to prevent clinical osteoporosis because we have been convinced that this is the appropriate thing to do by pharma hype. Maybe so, but that does not necessarily mean we shouldn't do it. Risk of fracture is clearly reduced by bisposphonates. Bisphosphonates appear safe and effacious and for a patient at an increased risk of osteoporotic fracture it is reasonable to offer that patient the option of prescription medication to mitigate that risk even though we may have not reached that point if not for the promotional efforts of drug companies. With the spotlight that has been focused on Pharma's antics, I want to believe there will be less disease mongering and both physicians and patients will be more skeptical and immune to influence.
Specifically in regard to the metabolic syndrome and relevant to disease mongering discussions, at least one drug company cannot be pleased with ADA's recent statement challenging the validity of the concept. I read today a two page ad from Sanofi Aventis in which "a newly discovered physiologic system" is highlighted, namely the endocannabinoid system which is alleged to be overactive in the metabolic syndrome Their drug, rimonibant is an antagonist of this system and FDA approval for treatment of the metabolic syndrome would be more valuable than treatment for obesity alone an application for which it has demonstrated some usefulness.
Fox Mulder believed the truth is out there somewhere.Physicians typically do as well, but it is harder to grasp the truth when we have serious doubts about the veracity of the data underlying our practice decisions.

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