When Annie Dennison was diagnosed with breast cancer last year,she readily followed advice from her medical team, agreeing toharsh treatments in the hope of curing her disease.

“You’re terrified out of your mind” after a diagnosis of cancer,said Dennison, 55, a retired psychologist from Orange County,Calif.

In addition to lumpectomy surgery, chemotherapy and othermedications, Dennison underwent six weeks of daily radiationtreatments. She agreed to the lengthy radiation regimen, she said,because she had no idea there was another option.

Medical research published in TheNew England Journal of Medicine in 2010 — six years before herdiagnosis — showed that a condensed, three-week radiation courseworks just as well as the longer regimen. A year later, theAmerican Society for Radiation Oncology, which writes medicalguidelines, endorsed theshorter course.

In 2013, the society went further and specifically told doctorsnot to begin radiation on women like Dennison — who was over 50,with a small cancer that hadn’t spread — without considering theshorter therapy.

“It’s disturbing to think that I might have been overtreated,”Dennison said. “I would like to make sure that other women and menknow this is an option.”

Dennison’s oncologist, Dr. David Khan of El Segundo, Calif.,notes that there are good reasons to prescribe a longer course ofradiation for some women.

Khan, an assistant clinical professor at UCLA, said he wasworried that the shorter course of radiation would increase therisk of side effects, given that Dennison had undergonechemotherapy as part of her breast cancer treatment. The latestradiation guidelines, issued in 2011, don’t include patients who’vehad chemo.

Yet many patients still aren’t told about their choices.

An exclusive analysis for Kaiser Health News found that only 48percent of eligible breast cancer patients today get the shorterregimen, in spite of the additional costs and inconvenience of thelonger type.

The analysis was completed by eviCore healthcare, a SouthCarolina-based medical benefit management company, which analyzedrecords of 4,225 breast cancer patients treated in the first halfof 2017. The women were covered by several commercial insurers. Allwere over age 50 with early-stage disease.

The data “reflect how hard it is to change practice,” said Dr.Justin Bekelman, associate professor of radiation oncology at theUniversity of Pennsylvania Perelman School of Medicine.

A growing number of patients and doctors are concerned aboutovertreatment, which is rampant across the health care system,argues Dr. Martin Makary, a professor of surgery and health policyat the Johns Hopkins University School of Medicine inBaltimore.

From duplicate blood tests to unnecessary knee replacements,millions of patients are being bombarded with screenings, scansand treatments that offer little or no benefit, Makary said.Doctors estimated that 21 percent of medical care is unnecessary,according to a survey Makary published in September in Plos One.

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Kaiser HealthNews (KHN) is a national health policy news service. It isan editorially independent program of the Henry J. Kaiser FamilyFoundation.

Unnecessary medical services cost the health care system atleast $210 billion a year, according to a 2009 report by theNational Academy of Medicine, a prestigious science advisorygroup.

Those procedures aren’t only expensive. Some clearly harmpatients.

Overzealous screening for cancers of the thyroid, prostate,breast and skin, for example, leads many older people to undergotreatments unlikely to extend their lives, but which can causeneedless pain and suffering, said Dr. Lisa Schwartz, a professor atthe Dartmouth Institute for Health Policy and ClinicalPractice.

“It’s just bad care,” said Dr. Rebecca Smith-Bindman, aprofessor at the University of California-San Francisco, whoseresearch has highlighted the risk of radiation from unnecessary CT scans and otherimaging.

Outdated treatments

All eligible breast cancer patients should be offered a shortercourse of radiation, said Dr. Benjamin Smith, an associateprofessor of radiation oncology at the University of Texas MDAnderson Cancer Center.

Studies show that side effects from the shorter regimen are thesame or evenmilder than traditional therapy, Smith said.

“Any center that offers antiquated, longer courses of radiationcan offer these shorter courses,” said Smith, lead author of theradiation oncology society’s2011 guidelines.

Smith, who is currently updating the expert guidelines, saidthere’s no evidence that women who’ve had chemo have more sideeffects if they undergo the condensed radiation course.

“There is no evidence in the literature to suggest that patientswho receive chemotherapy will have a better outcome if they receivesix weeks of radiation,” Smith said.

Shorter courses save money, too. Bekelman’s 2014 study inJAMA, the journal of the American Medical Association, foundthat women given the longer regimen faced nearly $2,900 more inmedical costs in the year after diagnosis.

The high rate of overtreatment in breast cancer is “shocking andappalling and unacceptable,” said Karuna Jaggar, executive directorof Breast Cancer Action, a San Francisco-based advocacy group.“It’s an example of how our profit-driven health system putsfinancial interests above women’s health and well-being.”

Just getting to the hospital for treatment imposes a burden onmany women, especially those in rural areas, Jaggar said. Ruralbreast cancer patients are more likely than urban women to choose a mastectomy, which removes the entire breast buttypically doesn’t require follow-up radiation.

Too many tests

Meg Reeves, 60, believes much of her treatment for early breastcancer in 2009 was unnecessary. Looking back, she feels as if shewas treated “with a sledgehammer.”

At the time, Reeves lived in a small town in Wisconsin and hadto travel 30 miles each way for radiation therapy. After shecompleted her course of treatment, doctors monitored her for eightyears with a battery of annual blood tests and MRIs. The bloodtests include screenings for tumor markers, which aim to detectrelapses before they cause symptoms.

Yet cancerspecialists have repeatedly rejected these kinds of expensiveblood tests and advanced imaging since 1997.

For survivors of early breast cancer like Reeves — who had nosigns of symptoms of relapse — “these tests aren’t helpful and canbe hurtful,” said Dr. Gary Lyman, a breast cancer oncologist andhealth economist at the Fred Hutchinson Cancer Research Center.Reeves’ primary doctor declined to comment.

In 2012, the AmericanSociety for Clinical Oncology, the leading medical group forcancer specialists, explicitly told doctors not toorder the tumor marker tests and advanced imaging — such asCT, PET andbone scans — for survivors of early-stage breast cancer.

Yet these tests remain common.

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Kaiser HealthNews (KHN) is a national health policy news service. It isan editorially independent program of the Henry J. Kaiser FamilyFoundation.

Thirty-seven percent of breast cancer survivors underwentscreening for tumor markers between 2007 and 2015, accordingto a studypresented in June at the American Society of ClinicalOncology’s annual meeting and publishedin the society’s journal online.

Sixteen percent of these survivors underwent advanced imaging.None of these women had symptoms of a recurrence, such as a breastlump, Lyman said.

Beyond wasted time and worry for women, these scans also exposethem to unnecessary radiation, a known carcinogen, Lyman said.A National CancerInstitute study estimated that 2 percent of all cancers inthe United States could be caused by medical imaging.

Paying the price

Health care costs per breast cancer patients monitored withadvanced imaging averaged nearly $30,000 in the year aftertreatment ended. That was about $11,600 more than for women whodidn’t get such follow-up tests, according to Lyman’s study. Womenmonitored with biomarkers had nearly $6,000 in additional healthcosts.

Reeves knows the costs of cancer treatment all too well.Although she had health insurance from her employer, she says shehad to sell her house to pay her medical bills. “It was financiallydevastating,” Reeves said.

“It’s the worst kind of financialtoxicity, because you’re incurring costs for something with nobenefit,” said Dr. Scott Ramsey, director of the HutchinsonInstitute for Cancer Outcomes Research.

Even simple blood tests take a toll, Reeves said.

Repeated needle sticks — including those from unnecessary annualblood tests — have scarred the veins in her left arm, the only onefrom which nurses can draw blood, she says. Nurses avoid drawingblood on her right side — the side of her breast surgery — becauseit could injure that arm, increasing the risk of a complicationcalled lymphedema, which causes painful arm swelling.

Reeves worries about the side effects of so many scans.

After treatment ended, her doctor also screened her with yearlyMRI scans using a dye called gadolinium. The Food and DrugAdministration is investigating the safety of the dye, whichleaves metal deposits in organs such as the brain. After sufferingso much during cancer treatment, she doesn’t want any more bad newsabout her health.

Becoming an advocate

Kathi Kolb, 63, was staring at 35 radiation treatments overseven weeks in 2008 for her early breast cancer. But she wasdetermined to educate herself and find another option.

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Kaiser HealthNews (KHN) is a national health policy news service. It isan editorially independent program of the Henry J. Kaiser FamilyFoundation.

“I had bills to pay, no trust fund, no partner with a bigsalary,” said Kolb, a physical therapist from South Kingstown, R.I.“I needed to get back to work as soon as I could.”

Kolb asked her doctor about a 2008 Canadian study,which was later published in the influential New England Journal ofMedicine, showing that three weeks of radiation was safe. He agreedto try it.

Even the short course left her with painful skin burns,blisters, swelling, respiratory infections and fatigue. She fearsthese symptoms would have been twice as bad if she had beensubjected to the full seven weeks.

“I saved myself another month of torture and being out of work,”Kolb said. “By the time I started to feel the effects of beingzapped [day] after day, I was almost done.”

A growing number of medical and consumer groups are working toeducate patients, so they can become their own advocates.

The Choosing Wisely campaign, launched in 2012 by the AmericanBoard of Internal Medicine (ABIM) Foundation, aims to raiseawareness about overtreatment. The effort, which has been joined by80 medical societies, has listed 500 practices to avoid. It advisesdoctors not to provide more radiation for cancer than necessary,and to avoid screening for tumor markers after early breastcancer.

“Patients used to feel like ‘more is better,’” said DanielWolfson, executive vice president of the ABIM Foundation. “Butsometimes less is more. Changing that mindset is a majorvictory.”

Yet Wolfson acknowledges that simply highlighting the problemisn’t enough.

Many doctors cling to outdated practices out of habit, said Dr.Bruce Landon, a professor of health care policy at Harvard MedicalSchool.

“We tend in the health care system to be pretty slow inabandoning technology,” Landon said. “People say, ‘I’ve alwaystreated it this way throughout my career. Why should I stopnow?’”

Many doctors say they feel pressured to order unnecessary testsout of fear of being sued for doing too little. Others say patients demand the services. Insurveys, some doctors blame overtreatment on financial incentives that reward physicians and hospitals fordoing more.

Because insurers pay doctors for each radiation session, forexample, those who prescribe longer treatments earn more money,said Dr. Peter Bach, director of Memorial Sloan Kettering’s Centerfor Health Policy and Outcomes in New York.

“Reimbursement drives everything,” said economist Jean Mitchell,a professor at Georgetown University’s McCourt School of PublicPolicy. “It drives the whole health care system.”

Smith-Bindman, the UC-San Francisco professor, said the causesof overtreatment aren’t so simple. The use of expensive imagingtests also has increased in managed care organizations in whichdoctors don’t profit from ordering tests, her researchshows.

“I don’t think it’s money,” Smith-Bindman said. “I think we havea really poor system in place to make sure people get care thatthey’re supposed to be getting. The system is broken in a whole lotof places.”

Dennison said she hopes to educate friends and others in thebreast cancer community about new treatment options and encouragethem to speak up. She said, “Patients need to be able to say ‘I’dlike to do it this way because it’s my body.’”

Kaiser HealthNews (KHN) is a national health policy news service. It isan editorially independent program of the Henry J. Kaiser FamilyFoundation. KHN’s coverage related to aging &improving care of older adults is supported by The John A. HartfordFoundation.