Read a transcript of one of Dr. Li’s cancer screening workshops for community doctors, and you might find yourself aghast at her flagrant dismissal of international best practices. “I tell my patients to do a follow-up after one year. If the test comes back normal two years in a row, then they can do follow-ups every three years,” she informs her trainees. “But how do you answer the questions on the exam? There we still have to follow international standards. The first two follow-ups are (only) every three years, and if the tests are all normal, then we can do it every five years after that.”
Those in the room all understand where Dr. Li — a pseudonym — is coming from, and her honesty wins smiles from her knowing trainees. Over-examination has become a favorite target for critics of China’s medical system, but Dr. Li isn’t trying to teach her trainees how to make some extra cash by prescribing unnecessary tests. Her words reflect a far more insidious logic: At Chinese hospitals, over-examination is the natural outcome of a deeply flawed and untrustworthy medical system.
Take cervical cancer, for example. One-fifth of new cervical cancer cases in the world each year come from China. In order to reduce the mortality rate of cervical cancer, as well as breast cancer, the country began to promote “two cancer” screenings in rural areas nationwide in 2009. In southwestern city Chongqing, where I conducted my research, free cervical cancer screenings were introduced the same year, and the municipality achieved full coverage in 2018. Beginning in 2012, the municipality changed its primary screening method from unreliable pap smears to the more accurate ThinPrep Cytologic Test (TCT), with community gynecologists receiving trainings on how to perform the new exams.
Yet more advanced technology and more intensive training have not led to improved results: Chongqing was ranked at the bottom of national cervical screening programs in 2018 with a primary screening detection rate of just 1%.
Why the disconnect? The first problem is who’s doing the primary screening. Most of the patients and medical resources in China are concentrated in large hospitals, whereas the community physicians primarily responsible for preliminary screening lack experience in observing and treating cervical cancer cases. The community hospitals in which they serve also do not always have the capacity or funds to provide TCTs, which cost more than pap smears. Meanwhile, even when community physicians take samples and make cultures, there are not enough experienced medical technicians and pathologists at their institutions to process the cultures and make accurate diagnoses.
The low detection rate of primary screenings at the community level means that hospital doctors farther along the chain cannot fully trust the results, and feel they can only reduce the number of missed diagnoses by increasing the frequency of testing.
Aware of the problem, health officials in Chongqing are trying to get around the lack of professional testers by promoting the adoption of a fully machine-operated HPV DNA virus test. On the surface, this asks less of community doctors, and seems to provide a simple solution to the primary screening dilemma. But it’s no cure-all, as doctors now must sort through a mess of testing reagents.
“There are only two FDA-approved testing reagents suggested for primary screening (in the U.S.),” Dr. Li told her students. “But we (in China) already have dozens of products on the market!”
Speaking to the class, Dr. Li angrily pinned the problem on a lack of oversight by China’s National Medical Products Administration, saying the current chaos in China’s medical testing market makes it impossible for doctors to confidently follow international standards.
“Others have just two products with good quality control, which can certainly be used as criteria for primary screening, but we have whatever!” she fumed. “Let me just ask you: When you get the results of these tests, do you dare to just let your patient leave?”
The rant seemed to provide a eureka moment for a few participants: “No wonder there are always people saying that their tests are negative, but when they go to a big hospital it’s already cancer,” one whispered.
Compounding the problem, the colposcopy tests needed if there are problems with the initial TCT or HPV DNA screenings require a much higher level of expertise and experience than most community doctors possess. The physicians in Li’s class all indicated that the colposcopy equipment they were given for practice produced much higher resolution images than what they’d typically use at their own hospitals, and while they told me the two-week training helped, it also made many even more anxious, since the procedure clearly takes a long time to master. “How many community hospitals are willing to retain a physician that specializes in colposcopies?” one attendee asked. “At least not our hospital. We do everything half-assed.”
In short, despite the best efforts of people like Dr. Li, there are too many uncontrollable factors embedded in China’s health care system to make cancer screenings reliable. Community physicians often have lower screening success rates due to a severe shortage of medical resources and experience. Localities cannot realize their hope to offset this lack of professionals by turning to new technologies, because the health care market is so poorly regulated.
The result is a system in which it is hard for community physicians to follow guidelines; for higher-level physicians at larger hospitals to trust the work done by community physicians; or even for community physicians to trust their own diagnoses. So everyone ends up over-examining as they try to reduce the rate of missed diagnoses or misdiagnoses through sheer volume.
In this context, the utility of trainings is limited. At the end of her two-week course, Dr. Li asked the participants, “Will you know what to do if you encounter such a patient (with a positive screening result) in the future?”
“Direct referrals to you!” several of the participants bluntly replied, only half-joking.
In the final open-book exam, the trainees all wrote down the internationally accepted standard for follow-up screenings, but they walked away with notebooks packed with Dr. Li’s more pragmatic advice: “Follow up in a year, administer a combination of TCT plus HPV DNA combination screening … And if you’re unsure, you can ask the patient to return every year.” The epidemic of over-examination grinds on.
Translator: Matt Turner; editors: Cai Yiwen and Kilian O’Donnell.
(Header image: Canopy/Corbis Creative/People Visual)