Causado por la artritis, comenzó como una molestia constante después de cumplir los 40, en gran parte por la presión del sobrepeso. Pero, aunque Lake logró perder 200 libras con dietas y ejercicio, el dolor en las rodillas persistió.

Dos años atrás, Lake sufrió un ataque sexual que la dejó con un trauma físico y psicológico. Se dañó las rodillas luchando contra el atacante que había irrumpido en su casa. Aunque logró escapar, sus rodillas nunca se recuperaron. Varias veces terminó en la sala de emergencias por el intenso dolor. El trabajo de Lake, que en parte era cargar maletas en aviones, la dejaba con frecuencia en un estado de desesperación.

Cuando un médico le dijo que un reemplazo de rodilla reduciría el dolor de la artritis en un 75%, Lake se alegró mucho.

“Pensé que el reemplazo de rodilla iba a ser una cura”, explicó la mujer, quien ahora tiene 52 años y vive en una zona rural de Iowa. “Me emocioné solo de pensar que por fin el dolor se iba a terminar y que tendría calidad de vida”.

Pero un año después de la cirugía en su rodilla derecha, Lake dijo que todavía está sufriendo por un dolor incapacitante que le impide trabajar.

“Tengo un dolor constante, 24 horas al día, 7 días a la semana”, contó. “Hay veces que ni siquiera puedo dormir”.

La mayoría de los reemplazos de rodilla se consideran exitosos y el procedimiento es conocido por ser .ÌýLa cantidad de cirugías se duplicó , con de procedimientos al año previstos para 2030.

Pero el sufrimiento de Lake ilustra los riesgos y las limitaciones de esta cirugía. Y a los médicos les preocupa cada vez más que el procedimiento se realice en exceso y que se sobrevaloren sus beneficios.

Las investigaciones sugieren que hasta un tercio de las personas que tienen un reemplazo de rodilla continúan experimentando , mientras que no está satisfecha con los resultados. Un encontró que el reemplazo de rodilla tenía “efectos mínimos en la calidad de vida”, especialmente para pacientes con artritis menos severa.

que se someten a un reemplazo de rodilla podrían no ser los candidatos apropiados para el procedimiento, debido a que sus síntomas de artritis no son lo suficientemente severos como para merecer una intervención agresiva, concluyó un estudio de 2014 publicado en Arthritis & Rheumatology.

“Hacemos demasiados reemplazos de rodilla”, dijo el doctor James Rickert, presidente de la Society for Patient Centered Orthopedics, que aboga por una atención de salud asequible. “Podemos debatir el número exacto; pero casi nadie discute que no estamos haciendo demasiadas”.

Aunque los estadounidenses están envejeciendo y aumentando de peso, esos factores por sí solos no explican el crecimiento explosivo del reemplazo de rodilla. El aumento podría estar impulsado por una mayor cantidad de lesiones entre los pacientes más jóvenes y una mayor disposición de los médicos a operar a personas no tan mayores, entre los 50 y 60 años, señaló Rickert, quien es cirujano ortopédico en Bedford, Indiana.ÌýEste cambio se ha producido porque los nuevos implantes pueden durar más tiempo —unos 20 años— antes de desgastarse.

Sin embargo, ni siquiera los modelos más nuevos duran para siempre. Con el tiempo, los implantes pueden aflojarse y desprenderse del hueso, causando dolor. Los componentes plásticos de la rodilla artificial se desgastan lentamente, creando desechos que pueden causar inflamación. El desgaste puede provocar que la rodilla se rompa. Los pacientes que no bajan de peso después de la cirugía pueden ejercer una presión adicional sobre los implantes, acortando aún más su vida útil.

Cuanto más jóvenes son los pacientes, más probable es que “sobrevivan” a los implantes de rodilla y requieran una segunda cirugía. Estos procedimientos de “revisión” son más difíciles de realizar por muchas razones, incluyendo la presencia de tejido de cicatrización de la cirugía original. El cemento óseo utilizado en la primera cirugía también puede ser difícil de extraer, y los huesos pueden fracturarse a medida que se extirpa la vieja rodilla artificial, señaló Rickert.

Las revisiones también pueden causar complicaciones. Entre los pacientes menores de 60 años, cerca del 35% de los hombres necesitan una cirugía de revisión, junto con el 20% de las mujeres, según un artículo publicado en .

Sin embargo, y centros quirúrgicos comercializan mucho los reemplazos de rodilla, con anuncios que muestran a los pacientes corriendo, andando en bicicleta e incluso jugando baloncesto después del procedimiento, señaló el doctor Nicholas DiNubile, cirujano ortopédico de Havertown, Pennsylvania, especializado en medicina del deporte. Aunque muchas personas que tienen rodillas artificiales pueden volver a hacer ejercicio moderado, como tenis en pareja, no es realista imaginar que vuelvan a jugar al baloncesto corriendo por toda la cancha, apuntó.

“Los hospitales compiten entre sí”, dijo DiNubile y agregó que el marketing puede llevar a los pacientes más jóvenes a pensar: “Voy a conseguir una nueva articulación y volveré a hacer todo lo que hacía antes”. Para Rickert, “la publicidad médica es gran parte del problema. Su propósito es vender estas cirugías a los pacientes”.

Rickert señaló que a algunos pacientes se les ofrece una cirugía que no necesitan y que el dinero puede ser la clave.

Los reemplazos de rodilla, que cuestan $31,000 en promedio, son “realmente cruciales para la salud financiera de hospitales y consultorios médicos”, dijo. “El doctor gana mucho más si hace la cirugía”.

Ignorando las alternativas

ÌýPero la cirugía no es la única manera de tratar la artritis.

Los pacientes al inicio de la enfermedad puede que no necesiten más que analgésicos de venta libre, consejos nutricionales, fisioterapia y educación sobre su afección, explicó Daniel Riddle, investigador de fisioterapia y profesor de la Universidad Virginia Commonwealth, en Richmond.

Los estudios muestran que estos enfoques pueden incluso ayudar a las personas con artritis más severa.

En publicado en Osteoarthritis and Cartilage en abril de 2018, los investigadores compararon tratamientos quirúrgicos y no quirúrgicos en 100 pacientes mayores elegibles para reemplazo de rodilla.

Durante dos años, todos los pacientes mejoraron, ya sea que se les ofreciera cirugía o una combinación de terapias no quirúrgicas. A los pacientes asignados aleatoriamente para someterse a un reemplazo inmediato de rodilla les fue mejor, mejorando el doble que los que recibieron terapia combinada, según lo medido en las pruebas médicas estándar de dolor y funcionamiento.

Pero la cirugía también conllevó riesgos. Los pacientes quirúrgicos desarrollaron cuatro veces más complicaciones, incluyendo infecciones, coágulos de sangre o rigidez de la rodilla lo suficientemente severa como para requerir otro procedimiento médico bajo anestesia. En general, que se someten a un reemplazo de rodilla muere dentro de los 90 días posteriores a la cirugía.

Es de destacar que la mayoría de los pacientes tratados con terapias no quirúrgicas estaban satisfechos con su progreso. Aunque todos eran elegibles para someterse a un reemplazo de rodilla más tarde, dos tercios optaron por no hacerlo.

Tia Floyd Williams sufrió de artritis dolorosa durante 15 años antes que se le reemplazara una rodilla en septiembre de 2017. Aunque el procedimiento pareció transcurrir sin problemas, el dolor volvió a aparecer después de unos cuatro meses, extendiéndose a las caderas y a la parte baja de la espalda.

Le dijeron que necesitaba una segunda cirugía más extensa para ponerle una vara en la parte inferior de la pierna, dijo Williams, de 52 años, de Nashville.

“A esas alturas pensaba que estaría haciendo la segunda rodilla, no rehaciendo la primera”, comentó Williams.

Otros pacientes, como Ellen Stutts, están contentos con sus resultados. A Stutts, en Durham, Carolina del Norte, le reemplazaron una rodilla en 2016 y la otra este año. “Estoy definitivamente mejor que antes de la cirugía”, aseguró Stutts.

Tomar Decisiones Informadas

ÌýLos médicos y economistas están cada vez más preocupados por la cirugía inapropiada de las articulaciones de todo tipo, no sólo de las rodillas.

El tratamiento inadecuado no sólo perjudica a los pacientes, sino también al sistema de atención de salud al aumentar los costos para todos, señaló el doctor John Mafi, profesor asistente de medicina de la Facultad de Medicina David Geffen de la UCLA.

Los reemplazos de rodilla realizados en 2014 costaron a pacientes, aseguradoras y contribuyentes más de $40,000 millones. Se proyecta que esos costos aumentarán a medida que la nación envejezca y deba enfrentar los efectos de la epidemia de obesidad, así como una población cada vez mayor.

Para evitar reemplazos articulares inapropiados, algunos sistemas de salud están produciendo sobre los riesgos, beneficios y límites de la cirugía para ayudar a los pacientes a tomar decisiones más informadas.

Danette Lake llegó a plantearse una cirugía de reemplazo de rodilla en su otra rodilla. Hoy no está segura. Teme que un segundo procedimiento la decepcione.

A veces pienso que es mejor quedarme con el dolor, reflexionó.

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The arthritis pain began as a dull ache in her early 40s, brought on largely by the pressure of unwanted weight. Lake managed to lose 200 pounds through dieting and exercise, but the pain in her knees persisted.

A sexual assault two years ago left Lake with physical and psychological trauma. She damaged her knees while fighting off her attacker, who had broken into her home. Although she managed to escape, her knees never recovered. At times, the sharp pain drove her to the emergency room. Lake’s job, which involved loading luggage onto airplanes, often left her in misery.

When a doctor said that knee replacement would reduce her arthritis pain by 75 percent, Lake was overjoyed.

“I thought the knee replacement was going to be a cure,” said Lake, now 52 and living in rural Iowa. “I got all excited, thinking, ‘Finally, the pain is going to end and I will have some quality of life.’”

But one year after surgery on her right knee, Lake said she’s still suffering.

“I’m in constant pain, 24/7,” said Lake, who is too disabled to work. “There are times when I can’t even sleep.”

Most knee replacements are considered successful, and the procedure is known for being Rates of the surgery , with procedures a year expected by 2030.

But Lake’s ordeal illustrates the surgery’s risks and limitations. Doctors are increasingly concerned that the procedure is overused and that its benefits have been oversold.

Research suggests that up to one-third of those who have knees replaced continue to experience , while are dissatisfied with the results. A found that knee replacement had “minimal effects on quality of life,” especially for patients with less severe arthritis.

who undergo knee replacement may not even be appropriate candidates for the procedure, because their arthritis symptoms aren’t severe enough to merit aggressive intervention, according to a 2014 study in Arthritis & Rheumatology.

“We do too many knee replacements,” said Dr. James Rickert, president of the Society for Patient Centered Orthopedics, which advocates for affordable health care, in an interview. “People will argue about the exact amount. But hardly anyone would argue that we don’t do too many.”

Although Americans are aging and getting heavier, those factors alone don’t explain the explosive growth in knee replacement. The increase may be fueled by a higher rate of injuries among younger patients and doctors’ greater willingness to operate on younger people, such as those in their 50s and early 60s, said Rickert, an orthopedic surgeon in Bedford, Ind.ÌýThat shift has occurred because new implants can last longer — perhaps 20 years — before wearing out.

Yet even the newest models don’t last forever. Over time, implants can loosen and detach from the bone, causing pain. Plastic components of the artificial knee slowly wear out, creating debris that can cause inflammation. The wear and tear can cause the knee to break. Patients who remain obese after surgery can put extra pressure on implants, further shortening their lifespan.

The younger patients are, the more likely they are to “outlive” their knee implants and require a second surgery. Such “revision” procedures are more difficult to perform for many reasons, including the presence of scar tissue from the original surgery. Bone cement used in the first surgery also can be difficult to extract, and bones can fracture as the older artificial knee is removed, Rickert said.

Revisions are also more likely to cause complications. Among patients younger than 60, about 35 percent of men need a revision surgery, along with 20 percent of women, according to a

Yet and surgery centers market knee replacements heavily, with ads that show patients running, bicycling, even playing basketball after the procedure, said Dr. Nicholas DiNubile, a Havertown, Pa., orthopedic surgeon specializing in sports medicine. While many people with artificial knees can return to moderate exercise — such as doubles tennis — it’s unrealistic to imagine them playing full-court basketball again, he said.

“Hospitals are all competing with each other,” DiNubile said. Marketing can mislead younger patients into thinking, “‘I’ll get a new joint and go back to doing everything I did before,’” he said. To Rickert, “medical advertising is a big part of the problem. Its purpose is to sell patients on the procedures.”

Rickert said that some patients are offered surgery they don’t need and that money can be a factor.

Knee replacements, which cost $31,000 on average, are “really crucial to the financial health of hospitals and doctors’ practices,” he said. “The doctor earns a lot more if they do the surgery.”

Ignoring Alternatives

Yet surgery isn’t the only way to treat arthritis.

Patients with early disease often benefit from over-the-counter pain relievers, dietary advice, physical therapy and education about their condition, said Daniel Riddle, a physical therapy researcher and professor at Virginia Commonwealth University in Richmond.

Studies show that these approaches can even help people with more severe arthritis.

In Ìýpublished in Osteoarthritis and Cartilage in April, researchers compared surgical and non-surgical treatments in 100 older patients eligible for knee replacement.

Over two years, all of the patients improved, whether they were offered surgery or a combination of non-surgical therapies. Patients randomly assigned to undergo immediate knee replacement did better, improving twice as much as those given combination therapy, as measured on standard medical tests of pain and functioning.

But surgery also carried risks. Surgical patients developed four times as many complications, including infections, blood clots or knee stiffness severe enough to require another medical procedure under anesthesia. In general, who undergo a knee replacement die within 90 days of surgery.

Significantly, most of those treated with non-surgical therapies were satisfied with their progress. Although all were eligible to have knee replacement later, two-thirds chose not to do it.

Tia Floyd Williams suffered from painful arthritis for 15 years before having a knee replaced in September 2017. Although the procedure seemed to go smoothly, her pain returned after about four months, spreading to her hips and lower back.

She was told she needed a second, more extensive surgery to put a rod in her lower leg, said Williams, 52, of Nashville.

“At this point, I thought I would be getting a second knee done, not redoing the first one,” Williams said.

Other patients, such as Ellen Stutts, are happy with their results. Stutts, in Durham, N.C., had one knee replaced in 2016 and the other replaced this year. “It’s definitely better than before the surgery,” Stutts said.

Making Informed Decisions

Doctors and economists are increasingly concerned about inappropriate joint surgery of all types, not just knees.

Inappropriate treatment doesn’t harm only patients; it harms the health care system by raising costs for everyone, said Dr. John Mafi, an assistant professor of medicine at the David Geffen School of Medicine at UCLA.

The replacements performed in 2014 cost patients, insurers and taxpayers more than $40 billion. Those costs are projected to surge as the nation ages and grapples with the effects of the obesity epidemic, and an aging population.

To avoid inappropriate joint replacements, some health systems are developing “decision aids,” easy-to-understand written about the risks, benefits and limits of surgery to help patients make more informed choices.

In 2009, Group Health introduced decision aids for patients considering joint replacement for hips and knees.

Blue Shield of California implemented a similar “shared decision-making” initiative.

Executives at the health plan have been especially concerned about the big increase in younger patients undergoing knee replacement surgery, said Henry Garlich, director of health care value solutions and enhanced clinical programs.

The percentage of knee replacements performed on people 45 to 64 increased from 30 percent in 2000 to 40 percent in 2015, according to the Agency for Healthcare Research and Quality.

Because the devices can wear out in as little as a few years, a younger person could outlive their knees and require a replacement, Garlich said. But “revision” surgeries are much more complicated procedures, with a higher risk of complications and failure.

“Patients think after they have a knee replacement, they will be competing in the Olympics,” Garlich said.

Danette Lake once planned to undergo knee replacement surgery on her other knee. Today, she’s not sure what to do. She is afraid of being disappointed by a second surgery.

Sometimes, she said, “I think, ‘I might as well just stay in pain.’”

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Kaiser Health News senior correspondent Liz Szabo moderated a discussion a panel of experts to explore overtreatment.

Our panelists were:

• Dr. Louise Davies,ÌýÌýAn associate professor ofÌý otolaryngology – head and neck surgery in The Dartmouth Institute for Health Policy & Clinical Practice
• Dr. Saurabh Jha, anÌýassociate professor of radiology at the University of Pennsylvania
• Dr. Barry Kramer, director of the division of cancer prevention at the National Cancer Institute
• Dr. Jacqueline Kruser, a pulmonologist and critical care physician at Northwestern University Feinberg School of Medicine
• Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine.

ºÚÁϳԹÏÍø News’ coverage related to aging and improving care of older adults is supported in part by .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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For frail nursing home residents, however, breast cancer surgery can harm their health and even hasten death, according to a study published Wednesday in JAMA Surgery.

The results have led some experts to question why patients who are fragile and advanced in years are screened for breast cancer, let alone given aggressive treatment.

The study examined the records of nearly 6,000 nursing home residents who had inpatient breast cancer surgery the past decade. It found that 31 to 42 percent died within a year of the procedure. That’s significantly higher than the 25 percent of nursing home residents who die in a typical year, said Dr. Victoria Tang, lead author and an assistant professor of geriatrics and hospital medicine at the University of California-San Francisco.

Although her study doesn’t include information about the cause of death, Tang said she suspects that many of the women died of underlying health problems or complications related to surgery, which can further weaken older patients. Patients who were the least able to take care of themselves before surgery, for example, were the most likely to die within the following year. Dementia also increased the risk of death.

It’s unlikely that many of the deaths were due to breast cancer, which often grows slowly in the elderly, Tang said. Breast cancers often take a decade to turn fatal.

“When someone gets breast cancer in a nursing home, it’s very unlikely to kill them,” said study co-author Dr. Laura Esserman, director of the UCSF

breast cancer center. “They are more likely to die from their underlying condition.”

Yet most patients in the study got sicker and less independent in the year following breast surgery.

Among patients who survived at least one year, 58 percent suffered a serious downturn in their ability to perform “activities of daily living,” such as dressing, bathing, eating, using the bathroom or walking across the room.

Women in the study, who were on average 82 years old, suffered from a variety of life-threatening health problems even before being diagnosed with breast cancer. About 57 percent suffered from cognitive decline, 36 percent had diabetes, 22 percent had heart failure, 17 percent had chronic lung disease, and 12 percent had survived a heart attack.

The high mortality rate in the study is striking because breast surgery is typically considered a low-risk procedure, said Dr. Deborah Korenstein, chief of general internal medicine at New York’s Memorial Sloan Kettering Cancer Center.

The paper provided an example of how sick, elderly people can suffer from surgery. An 89-year-old woman with dementia who underwent a mastectomy became confused after surgery and pulled off all her bandages. Health care workers had to restrain her in bed to prevent her from pulling off the bandages again. The woman died 15 months later of a heart attack.

Surgery late in life is more common than many realize. One-third of Medicare patients undergo surgery in the year before they die, according to a Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week.

Nearly 1 in 5 women with severe cognitive impairment, such as Alzheimer’s disease, get regular mammograms, according to a study in the American Journal of Public Health.

The new study leaves some important questions unanswered.

The paper didn’t include healthier nursing home residents who are strong enough to undergo outpatient surgery, said Dr. Heather Neuman, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health. These women may fare better than those who are very ill.

Esserman and Tang said their findings suggest doctors need to treat breast cancer differently in very frail patients.

“People think, ‘Oh, a lumpectomy is nothing,’” Esserman said. “But it’s not nothing in someone who is old and frail.”

In recent years, doctors have tried to scale back breast cancer therapy to help women avoid serious side effects. In June, for example, researchers announced that sophisticated genetic tests can help predict which breast cancers are less aggressive, a finding that could allow 70 percent of patients to avoid chemotherapy.

The Medicare database used in this study didn’t mention whether any of the patients had chemotherapy, radiation or other outpatient care. So the UCSF researchers acknowledged that they can’t rule out the possibility that some of the women suffered complications due to these other therapies. In general, however, authors noted that only 6 percent of nursing home residents with cancer are treated with chemotherapy or radiation.

The authors said doctors should give very frail patients the option of undergoing less aggressive therapy, such as hormonal treatments. In other cases, doctors could offer to simply treat symptoms as they appear.

The new study raises questions about the value of screening nursing home residents for breast cancer, Korenstein said. Although the hasn’t set an upper age limit for breast cancer screening, it advises women to be screened as long as they’re in good health and expected to live at least another decade.

Residents of nursing homes generally can’t expect to live long enough to benefit from breast screening, Korenstein said.

“It makes no sense to screen people in nursing homes,” Korenstein said. “The harms of doing anything about what you find are far going to outweigh the benefits.”

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The Ìýwho perhaps more than anyone else is responsible for creating a billion-dollar vitamin D sales and testing juggernaut, elevates his own levels of the stuff with supplements and fortified milk. When he bikes outdoors, he won’t put sunscreen on his limbs. He has written book-length odes to vitamin D, and has warned in multiple scholarly articles about a that explains disease and suboptimal health across the world.

is so intense that it extends to the dinosaurs. What if the real problem with that asteroid 65 million years ago wasn’t a lack of food, but the weak bones that follow a lack of sunlight? “I sometimes wonder,” Holick has written, “did the dinosaurs die of rickets and osteomalacia?”

Holick’sÌýrole in drafting national vitamin D guidelines, and the embrace of his message by mainstream doctors and wellness gurus alike, have helped push supplement sales to $936 million in 2017.ÌýThat’s a ninefold increase over the previous decade. Lab tests for vitamin D deficiency have spiked, too: Doctors ordered more than 10 million for Medicare patients in 2016, up 547 percent since 2007, at a cost of $365 million.ÌýAbout adults 60 and older now take vitamin D supplements.

But few of the Americans swept up in are likely aware that the industry has sent a lot of money Holick’s way. A Kaiser Health News investigation found that he has used his prominent position in the medical community to promote practices that financially benefit corporations that have given him hundreds of thousands of dollars — including drugmakers, the indoor-tanning industry and one of the country’s largest commercial labs.

In an interview, Holick acknowledged he has worked as a consultant to Quest Diagnostics, which performs vitamin D tests, since 1979. Holick, 72, said that industry funding “doesn’t influence me in terms of talking about the health benefits of vitamin D.”

There is no question that the hormone is important. Without enough of it, bones can become , causing a condition called rickets in children and osteomalacia in adults. The issue is how much vitamin D is healthy, and what level constitutes deficiency.

Holick’s crucial role in shaping that debate occurred in 2011. Late the previous year, the prestigious National Academy of Medicine (then known as the Institute of Medicine), a group of independent scientific experts, issued a comprehensive, on vitamin D deficiency. It that the vast majority of Americans get plenty of the hormone through diet and sunlight, and advised doctors to test only of vitamin D-related disorders, such as osteoporosis.

A few months later, in June 2011, Holick oversaw the publication of a report that took a starkly different view. The paper, in the peer-reviewed , was on behalf of the Endocrine Society, the field’s foremost professional group, whose guidelines are widely used by hospitals, physicians and commercial labs nationwide, including Quest. The society adopted Holick’s position that “vitamin D deficiency is very common in all age groups” and advocated a huge expansion of vitamin D testing, targeting more than half the United States population, including those who are black, Hispanic or obese — groups that tend to have lower vitamin D levels than others.

The were a financial windfall for the vitamin D industry. By advocating such widespread testing, the Endocrine Society directed more business to Quest and other commercial labs. Vitamin D tests are now the lab test covered by Medicare.

The guidelines benefited the vitamin D industry in another important way. Unlike the National Academy, which concluded that patients have sufficient vitamin D when their blood levels are at or above 20 nanograms per milliliter, the Endocrine Society said vitamin D levels need to be much higher — at least 30 nanograms per milliliter. Many commercial labs, including Quest and LabCorp, adopted the higher standard.

Yet there’s no evidence that people with the higher level are any healthier than those with the lower level, said Dr. Clifford Rosen, a senior scientist at the Maine Medical Center Research Institute and co-author of the National Academy report. Using the Endocrine Society’s higher standard creates the appearance of an epidemic, he said, because it labels 80 percent of Americans as having inadequate vitamin D.

“We see people being tested all the time and being treated based on a lot of wishful thinking, that you can take a supplement to be healthier,” Rosen said.

Patients with low vitamin D levels are often prescribed supplements and instructed to get checked again in a few months, said Dr. Alex Krist, a family physician and vice chairman of the U.S. Preventive Services Task Force, an expert panel that issues health advice. Many physicians then repeat the test once a year. For labs, “it’s in their financial interest” to label patients with low vitamin D levels, Krist said.

In a 2010 book, “The Vitamin D Solution,” Holick gave readers tips to encourage them to get their blood tested. For readers worried about potential out-of-pocket costs for vitamin D tests — they range from — Holick listed the precise reimbursement codes that doctors should use when requesting insurance coverage. “If they use the wrong coding when submitting the claim to the insurance company, they won’t get reimbursed and you will wind up having to pay for the test,” Holick wrote.

Holick acknowledged financial ties with Quest and other companies in the financial disclosure statement published with the Endocrine Society guidelines. In an interview, he said that working for Quest for four decades — he is currently paid $1,000 a month — hasn’t affected his medical advice. “I don’t get any additional money if they sell one test or 1 billion,” Holick said.

A Quest spokeswoman, Wendy Bost, said the company seeks the advice of a number of expert consultants. “We feel strongly that being able to work with the top experts in the field, whether it’s vitamin D or another area, translates to better quality and better information, both for our patients and physicians,” Bost said.

Since 2011, Holick’s advocacy has been embraced by the wellness-industrial complex. , cites his writing. has described vitamin D as “the No. 1 thing you need more of,” telling his audience that it can help them avoid heart disease, depression, weight gain, memory loss and cancer. And website tells readers that “knowing your vitamin D levels might save your life.” Mainstream doctors have pushed the hormone, including Dr. Walter Willett, a widely respected professor at Harvard Medical School.

Today, seven years after the dueling academic findings, the leaders of the National Academy report are struggling to be heard above the clamor for more sunshine pills.

“There isn’t a ‘pandemic,’” A. Catharine Ross, a professor at Penn State and chair of the committee that wrote the report, said in an interview. “There isn’t a widespread problem.”

Ties To Drugmakers And Tanning Salons

In “The Vitamin D Solution,” Holick describes his promotion of vitamin D as a lonely crusade. “Drug companies can sell fear,” he writes, “but they can’t sell sunlight, so there’s no promotion of the sun’s health benefits.”

Yet Holick also has extensive financial ties to the pharmaceutical industry. He received nearly $163,000 from 2013 to 2017 from pharmaceutical companies, according to , which tracks payments from drug and device manufacturers. The companies paying him included Sanofi-Aventis, which ; Shire, which makes drugs for hormonal disorders that are given with vitamin D; Amgen, which makes an osteoporosis treatment; and Roche Diagnostics and Quidel Corp., which both make vitamin D tests.

The database includes only payments made since 2013, but Holick’s record of being compensated by drug companies started before that. In his 2010 book, he describes visiting South Africa to give “talks for a pharmaceutical company,” whose president and chief executive were in the audience.

Holick’s ties to the tanning industry also have drawn scrutiny. Although Holick said he doesn’t advocate tanning, he has described as a “recommended source” of vitamin D “when used in moderation.”

Holick has acknowledged accepting research money from the UV Foundation — of the now-defunct — which gave $150,000 to Boston University from 2004 to 2006, earmarked for Holick’s research. The International Agency for Research on Cancer classified tanning beds as in 2009.

In 2004, the tanning-industry associations led Dr. Barbara Gilchrest, who then was head of Boston University’s dermatology department, to ask Holick from the department. He did so, but remains a professor at the medical school’s department of endocrinology, diabetes and nutrition and weight management.

In “The Vitamin D Solution,” Holick wrote that he was “forced” to give up his position due to his “stalwart support of sensible sun exposure.” He added, “Shame on me for challenging one of the dogmas of dermatology.”

Although Holick’s website lists him as a member of the , an academy spokeswoman, Amanda Jacobs, said he was not a current member.

Dr. Christopher McCartney, chairman of the Endocrine Society’s clinical guidelines subcommittee, said the society has put in place on conflict of interest since its vitamin D guidelines were released. The society’s current policies would not allow the chairman of the guideline-writing committee to have financial conflicts.

A Miracle Pill Loses Its Luster

Enthusiasm for vitamin D among medical experts has dimmed in recent years, as rigorous clinical trials have failed to confirm the benefits suggested by early, preliminary studies. A found no evidence that vitamin D reduces the risk of , or falls in the elderly. And most scientists say to know if vitamin D can prevent chronic diseases that aren’t related to bones.

Although the amount of vitamin D in a typical daily supplement is generally considered safe, it is possible to take too much. In 2015, an article in linked blood levels as low as 50 nanograms per milliliter with an increased risk of death.

Some researchers say vitamin D may never have been the miracle pill that it appeared to be. Sick people who stay indoors tend to have low vitamin D levels; their poor health is likely the cause of their low vitamin D levels, not the other way around, said Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women’s Hospital in Boston. Only really rigorous studies, which randomly assign some patients to take vitamin D and others to take placebos, can provide definitive answers about vitamin D and health. Manson is leading one such study, involving 26,000 adults, expected to be published in November.

A number of insurers and health experts have begun to view widespread vitamin D testing as unnecessary and expensive. In 2014, the said there wasn’t enough evidence to recommend for or against routine vitamin D screening. In April, the task force explicitly recommended that older adults outside of nursing homes avoid taking vitamin D supplements .

In 2015, Excellus BlueCross BlueShield highlighting the overuse of vitamin D tests. In 2014, the insurer spent $33 million on 641,000 vitamin D tests. “That’s an astronomical amount of money,” said Dr. Richard Lockwood, Excellus’ vice president and chief medical officer for utilization management. More than 40 percent of Excellus patients tested had no medical reason to be screened.

In spite of Excellus’ efforts to rein in the tests, vitamin D usage has remained high, Lockwood said. “It’s very hard to change habits,” he said, adding:Ìý“The medical community is not much different than the rest of the world, and we get into fads.”

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Here’s a recent story she wrote on the topic and others she has done as part of the Treatment Overkill series.

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Gulati también animó a su propio padre a tomarlas: “Papá, deberías tomar estas vitaminas, porque cada cardiólogo las toma o las receta a sus pacientes”, recordó la médica, que ahora es jefa de Cardiología de la University of Arizona College of Medicine-Phoenix.

Pero solo unos años más tarde, se encontró cambiando de dirección, después que rigurosos ensayos clínicos descubrieran que ni la ni los suplementos de ácido fólico hacían nada para proteger el corazón. Peor aún, los estudios relacionaban altas dosis de vitamina E con un mayor riesgo de , y .

“‘Tal vez quieras dejar de tomarlas'”, le dijo Guata a su padre.

, incluido el 68% de los mayores de 65 años, según una encuesta de Gallup de 2013. En este grupo, el 29% toma cuatro o más suplementos al día, reveló un de 2017 publicado en el Journal of Nutrition.

A menudo, los estudios preliminares inducen a consumir vitaminas cuando solo se trata de un “resultado prometedor”. Y ese consumo muchas veces no se detiene, a pesar que investigaciones más rigurosas, que pueden tomar muchos años, casi nunca encuentran que las vitaminas previenen enfermedades y, es más, en algunos casos, descubren que causan daño.

“El entusiasmo tiende a superar la evidencia”, dijo la doctora JoAnn Manson, jefa de Medicina Preventiva en el Brigham and Women’s Hospital de Boston.

No hay que los suplementos dietéticos prevengan enfermedades crónicas en el estadounidense promedio, dijo Manson. Y aunque han tenido resultados positivos, esos hallazgos no han sido lo suficientemente fuertes como para recomendar suplementos al , agregó.

Los Institutos Nacionales de Salud han gastado más de $2.4 mil millones desde 1999 en el estudio de vitaminas y minerales. Sin embargo, para “toda la investigación que hemos realizado, ”, dijo la doctora Barnett Kramer, directora de prevención del cáncer en el Instituto Nacional del Cáncer.

En busca de la bala mágica

Kramer dijo que gran parte del problema podría ser que la investigación nutricional se ha basado en suposiciones erróneas, incluida la idea que las personas necesitan más vitaminas y minerales de lo que proporciona una dieta típica; que las dosis grandes son siempre seguras; y que los científicos pueden concentrar los beneficios de vegetales como el brócoli en una píldora diaria.

Los alimentos ricos en vitaminas pueden curar enfermedades relacionadas con la deficiencia. Se demostró que las naranjas y los limones verdes lograron en marineros, en el siglo XVIII. Y la investigación ha demostrado durante mucho tiempo que las poblaciones que comen muchas tienden a ser .

Pero cuando los investigadores trataron de incluir todos los ingredientes clave de una dieta saludable en una cápsula, los esfuerzos fallaron, agregó Kramer.

Es posible que los químicos en las frutas y vegetales en su plato trabajen juntos de maneras que los científicos no entienden completamente, y que no puedan replicarse en una píldora, dijo Marjorie McCullough, directora estratégica de Epidemiología Nutricional de la Sociedad Americana del Cáncer.

Tal vez, más importante es que, de todas formas, la mayoría de los estadounidenses obtienen muchos de los elementos esenciales. Aunque la dieta occidental tiene muchos problemas, demasiado sodio, azúcar, grasas saturadas y calorías, en general, no le faltan vitaminas, dijo Alice Lichtenstein, profesora de la Facultad de Ciencias y Política de Nutrición de la Universidad de Tufts.

Y aunque hay más de para elegir, y todavía que los estadounidenses satisfagan sus necesidades nutricionales con alimentos, especialmente .

Además, la comida estadounidense está altamente fortificada: con , , vitamina B en la harina, e incluso calcio en algunas marcas de jugo de naranja.

Sin siquiera darse cuenta, alguien que come un almuerzo o desayuno típico “esencialmente está consumiendo un multivitamínico”, dijo la periodista Catherine Price, autora de “Vitamania: cómo las vitaminas revolucionaron la forma en que pensamos acerca de los alimentos”.

Eso puede hacer que el estudio de las vitaminas sea aún más complicado, dijo Price. Los investigadores pueden tener problemas para encontrar un verdadero grupo de control, sin exposición a suplementos de vitaminas. Si todos en un estudio consumen alimentos enriquecidos, las vitaminas pueden parecer menos efectivas.

El cuerpo naturalmente regula los niveles de muchos nutrientes, como la vitamina C y las vitaminas B, al excretar lo que no necesita a través de la orina, explicó Kramer. “Es casi imposible evitar el consumo de vitaminas”.

No todos los expertos están de acuerdo. El doctor Walter Willett, profesor de la Harvard T.H. Chan School of Public Health, dijo que es razonable tomar un multivitamínico diario “como un reaseguro”. Willett dijo que los ensayos clínicos subestiman los verdaderos beneficios de los suplementos porque no son lo suficientemente largos, duran solo de cinco a 10 años. Podría llevar décadas detectar una menor tasa de cáncer o enfermedad cardíaca en los que toman vitaminas, dijo.

Para Charlsa Bentley, de 67 años, estar al día con la última investigación sobre nutrición puede ser frustrante. Dejó de tomar calcio después que los estudios descubrieron que no protege contra las fracturas óseas. Estudios adicionales sugieren que los suplementos de calcio aumentan el riesgo de cálculos renales y enfermedades cardíacas.

“Mastiqué esos suplementos de calcio, y luego un estudio dijo que no servían para nada”, dijo Bentley, de Austin, Texas. “Es difícil saber qué es efectivo y qué no”.

Bentley todavía toma cinco suplementos por día: un complejo multivitamínico para prevenir la sequedad en los ojos, magnesio para evitar los calambres mientras hace ejercicio, uno de levadura roja para prevenir la diabetes, coenzima Q10 para la salud general y vitamina D, según la recomendación de su médico.

Al igual que dietéticos, Bentley también hace ejercicio regularmente: juega tenis de tres a cuatro veces por semana, y controla lo que come.

Las personas que toman vitaminas tienden a ser más saludables, más ricas y mejor educadas que las que no los consumen, dijo Kramer. Probablemente sean menos propensas a sucumbir a una enfermedad cardíaca o cáncer, ya sea que tomen suplementos o no. Eso puede sesgar los resultados de la investigación, haciendo que las vitaminas parezcan más efectivas de lo que realmente son.

¿Demasiado de algo bueno?

Tomar dosis grandes de vitaminas y minerales, usando cantidades que las personas nunca podrían consumir sólo con alimentos, podría ser aún más problemático.

“Hay algo atractivo acerca de tomar un producto natural, incluso si lo tomas de una manera totalmente antinatural”, dijo Price.

Los primeros estudios, por ejemplo, sugirieron que el beta caroteno, una sustancia que se encuentra en las zanahorias, podría ayudar a prevenir el cáncer.

En las pequeñas cantidades proporcionadas por las frutas y verduras, el betacaroteno y otras sustancias similares parecen proteger al cuerpo de un proceso llamado oxidación, que daña las células sanas, explicó el doctor Edgar Miller, profesor de medicina en la Escuela de Medicina Johns Hopkins.

Los expertos se sorprendieron cuando dos grandes estudios bien diseñados en la década de los 90 descubrieron que las píldoras de beta caroteno en realidad aumentaban las tasas de cáncer de pulmón. Del mismo modo, un ensayo clínico publicado en 2011 descubrió que la vitamina E, también antioxidante, aumentaba en un 17% el riesgo de cáncer de próstata en hombres. Estos estudios recordaron a los investigadores que la oxidación no es del todo mala; ayuda a matar bacterias y células malignas, eliminándolas antes que puedan convertirse en tumores, dijo Miller.

“Las vitaminas no son inertes”, dijo el doctor Eric Klein, experto en cáncer de próstata de la Clínica Cleveland que dirigió el estudio de vitamina E. “Son agentes biológicamente activos”. Tenemos que pensar en ellos de la misma manera que las drogas. Si tomas una dosis demasiado alta, causan efectos secundarios”.

Gulati, la doctora en Phoenix, dijo que su experiencia inicial recomendando suplementos a su padre le enseñó a ser más cautelosa. “Deberíamos ser médicos responsables y esperar los datos”.

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She urged her father to pop the pills as well: “Dad, you should be on these vitamins, because every cardiologist is taking them or putting their patients on [them],” recalled Gulati, now chief of cardiology for the University of Arizona College of Medicine-Phoenix.

But just a few years later, she found herself reversing course, after rigorous clinical trials found neither nor folic acid supplements did anything to protect the heart. Even worse, studies linked high-dose vitamin E to a higher risk of , and

“‘You might want to stop taking [these],’” Gulati told her father.

More than supplements, including 68 percent of those age 65 and older, according to a 2013 Gallup poll. Among older adults, 29 percent take four or more supplements of any kind, according to a Journal of Nutrition published in 2017.

Often, preliminary studies fuel irrational exuberance about a promising dietary supplement, leading millions of people to buy in to the trend. Many never stop. They continue even though more rigorous studies — which can take many years to complete — almost never find that vitamins prevent disease, and in some cases cause harm.

“The enthusiasm does tend to outpace the evidence,” said Dr. JoAnn Manson, chief of preventive medicine at Boston’s Brigham and Women’s Hospital.

There’s that dietary supplements prevent chronic disease in the average American, Manson said. And while a have had positive results, those findings haven’t been strong enough to , she said.

The National Institutes of Health has spent more than $2.4 billion since 1999 studying vitamins and minerals. Yet for “all the research we’ve done, we ,” said Dr. Barnett Kramer, director of cancer prevention at the National Cancer Institute.

In Search Of The Magic Bullet

A big part of the problem, Kramer said, could be that much nutrition research has been based on faulty assumptions, including the notion that people need more vitamins and minerals than a typical diet provides; that megadoses are always safe; and that scientists can boil down the benefits of vegetables like broccoli into a daily pill.

Vitamin-rich foods can cure diseases related to vitamin deficiency. Oranges and limes were famously shown to sailors. And research has long shown that populations that tend to be than others.

But when researchers tried to deliver the key ingredients of a healthy diet in a capsule, Kramer said, those efforts nearly always failed.

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It’s possible that the chemicals in the fruits and vegetables on your plate work together in ways that scientists don’t fully understand — and which can’t be replicated in a tablet, said Marjorie McCullough, strategic director of nutritional epidemiology for the American Cancer Society.

More important, perhaps, is that most Americans get plenty of the essentials, anyway. Although the Western diet has a lot of problems — too much sodium, sugar, saturated fat and calories, in general — it’s not short on vitamins, said Alice Lichtenstein, a professor at the Friedman School of Nutrition Science and Policy at Tufts University.

And although there are more than from which to choose, and still that Americans meet their nutritional needs with food, especially

Also, American food is highly fortified — with in milk, , B vitamins in flour, even calcium in some brands of orange juice.

Without even realizing it, someone who eats a typical lunch or breakfast “is essentially eating a multivitamin,” said journalist Catherine Price, author of “Vitamania: How Vitamins Revolutionized the Way We Think About Food.”

That can make studying vitamins even more complicated, Price said. Researchers may have trouble finding a true control group, with no exposure to supplemental vitamins. If everyone in a study is consuming fortified food, vitamins may appear less effective.

The body naturally regulates the levels of many nutrients, such as vitamin C and many B vitamins, Kramer said, by excreting what it doesn’t need in urine. He added: “It’s hard to avoid getting the full range of vitamins.”

Not all experts agree. Dr. Walter Willett, a professor at the Harvard T.H. Chan School of Public Health, says it’s reasonable to take a daily multivitamin “for insurance.” Willett said that clinical trials underestimate supplements’ true benefits because they aren’t long enough, often lasting five to 10 years. It could take decades to notice a lower rate of cancer or heart disease in vitamin takers, he said.

Vitamin Users Start Out Healthier

For Charlsa Bentley, 67, keeping up with the latest nutrition research can be frustrating. She stopped taking calcium, for example, after studies found it doesn’t protect against Additional studies suggest that calcium supplements increase the

“I faithfully chewed those calcium supplements, and then a study said they didn’t do any good at all,” said Bentley, from Austin, Texas. “It’s hard to know what’s effective and what’s not.”

Bentley still takes five supplements a day: a multivitamin to prevent dry eyes, magnesium to prevent cramps while exercising, red yeast rice to prevent diabetes, coenzyme Q10 for overall health and vitamin D based on her doctor’s recommendation.

Like many , Bentley also exercises regularly — playing tennis three to four times a week — and watches what she eats.

People who take vitamins tend to be healthier, wealthier and better educated than those who don’t, Kramer said. They are probably less likely to succumb to heart disease or cancer, whether they take supplements or not. That can skew research results, making vitamin pills seem more effective than they really are.

Faulty Assumptions

Preliminary findings can also lead researchers to the wrong conclusions.

For example, scientists have long observed that people with high levels of are more likely to have heart attacks. Because folic acid can lower homocysteine levels, researchers once hoped that folic acid supplements would prevent heart attacks and strokes.

In a series of clinical trials, folic acid pills lowered homocysteine levels but had no overall benefit for heart disease, Lichtenstein said.

Studies of fish oil also may have led researchers astray.

When studies of large populations showed that people who eat lots of seafood had fewer heart attacks, many assumed that the benefits came from the omega-3 fatty acids in fish oil, Lichtenstein said.

have failed to show that fish oil supplements prevent heart attacks. A clinical trial of and vitamin D, whose results are expected to be released within the year, may provide clearer ideas about whether they prevent disease.

But it’s possible the benefits of sardines and salmon have nothing to do with fish oil, Lichtenstein said. People who have fish for dinner may be healthier due to what they don’t eat, such as meatloaf and cheeseburgers.

“Eating fish is probably a good thing, but to show that taking fish oil [supplements] does anything for you,” said Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic Foundation.

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Too Much Of A Good Thing?

Taking megadoses of vitamins and minerals, using amounts that people could never consume through food alone, could be even more problematic.

“There’s something appealing about taking a natural product, even if you’re taking it in a way that is totally unnatural,” Price said.

Early studies, for example, suggested that beta carotene, a substance found in carrots, might help prevent cancer.

In the tiny amounts provided by fruits and vegetables, beta carotene and similar substances appear to protect the body from a process called oxidation, which damages healthy cells, said Dr. Edgar Miller, a professor of medicine at Johns Hopkins School of Medicine.

Experts were shocked when two large, well-designed studies in the 1990s found that beta carotene pills actually increased lung cancer rates. Likewise, a clinical trial published in 2011 found that , also an antioxidant, increased the risk of prostate cancer in men by 17 percent. Such studies reminded researchers that oxidation isn’t all bad; it helps kill bacteria and malignant cells, wiping them out before they can grow into tumors, Miller said.

“Vitamins are not inert,” said Dr. Eric Klein, a prostate cancer expert at the Cleveland Clinic who led the vitamin E study. “They are biologically active agents. We have to think of them in the same way as drugs. If you take too high a dose of them, they cause side effects.”

Gulati, the physician in Phoenix, said her early experience with recommending supplements to her father taught her to be more cautious. She said she’s waiting for the results of large studies — such as the trial of fish oil and vitamin D — to guide her advice on vitamins and supplements.

“We should be responsible physicians,” she said, “and wait for the data.”

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Sufría de una larga lista de problemas de salud, incluyendo insuficiencia cardíaca y enfermedad pulmonar crónica, y ambas condiciones podían dejarla sin aliento.

Cuando llegó el momento, Stanich le dijo a su hija que quería morir de muerte natural, y la hija firmó una directiva de “no resucitación”, o DNR, ordenando a los médicos que no la reanimaran si su corazón se detenía.

Sin embargo, en 2008, por una crisis de falta de aliento, Stanich terminó en una sala de emergencias de San Francisco, California, en donde decidieron colocarle un desfibrilador en su pecho, un dispositivo médico para mantenerla con vida a través de una poderosa descarga eléctrica. En ese momento, Stanich no entendió completamente lo que había acordado, a pesar que firmó un documento que otorgaba permiso para el procedimiento, dijo su hija, Susan Giaquinto.

Esa claridad vino solo durante una visita posterior a un hospital diferente, cuando un sorprendido doctor de la sala de emergencia vio un desfibrilador que sobresalía del pecho delgado de la paciente que, además, tenía un DNR. Para horror de Stanich, el médico le explicó que el dispositivo no eliminaría el dolor y que la sacudida sería “tan fuerte que la lanzaría al otro lado de la habitación”, dijo Giaquinto, quien acompañó a su madre en ambas visitas al hospital.

Cirugías como ésta se han vuelto demasiado comunes en personas que están cerca del final de la vida, dicen expertos. Casi se someten a una operación el año anterior a su muerte, aunque la evidencia muestra que muchos tienen más probabilidades de sufrir daños que de beneficiarse del procedimiento.

La práctica está impulsada por incentivos financieros que recompensan a los médicos por realizar procedimientos, así como por una cultura médica en la que pacientes y doctores son reacios a hablar sobre cómo las intervenciones quirúrgicas deberían decidirse de manera más juiciosa, dijo la doctora Rita Redberg, cardióloga que trató a Stanich cuando se atendió en el segundo hospital.

“Tenemos una cultura que cree en una atención muy agresiva”, dijo Redberg, quien se especializa en enfermedades cardíacas en las mujeres en la Universidad de California-San Francisco. “A menudo no consideramos la posibilidad de beneficio y la de daño, y cómo eso cambia cuando se envejece. Tampoco podemos tener conversaciones sobre lo que los pacientes valoran más”.

Si bien las cirugías suelen salvar las vidas de personas más jóvenes, operar en pacientes frágiles y de mayor edad raramente los ayuda a vivir más tiempo o les devuelve la calidad de vida que solían tener, indica un artículo de 2016 publicado en .

El costo de estas cirugías, generalmente pagadas por Medicare, el programa de seguro de salud del gobierno para personas mayores de 65 años, implica más que dinero, dijo la doctora Amber Barnato, profesora de Política de Salud y Práctica Clínica del Instituto Dartmouth. Los pacientes mayores que se someten a una cirugía a menos de un año de su muerte pasaron 50% más tiempo en el hospital que otros, y casi el doble de días en cuidados intensivos.

Y aunque algunos octogenarios fuertes tienen muchos años por delante, los estudios muestran que las cirugías también son habituales entre aquellos que son mucho más frágiles.

Dieciocho por ciento de los pacientes de Medicare se someten a una cirugía en su último mes de vida y 8% en su última semana, según un estudio de 2011 publicado en .

Según , más del 12% de los desfibriladores se implantaron en personas mayores de 80 años. Los médicos colocan alrededor de 158,000 de estos dispositivos cada año, según el Colegio Americano de Cardiología. El del procedimiento es de aproximadamente $60,000.

Los procedimientos que se llevan a cabo en adultos mayores van desde operaciones importantes que requieren recuperaciones prolongadas hasta cirugías relativamente menores realizadas en el consultorio de un médico, como la extirpación de cánceres de piel no mortales, que probablemente nunca causarán ningún problema.

La dirigida por la doctora Eleni Linos ha demostrado que las personas con una expectativa de vida limitada reciben tratamiento para cánceres de piel no mortales tan agresivamente como los pacientes más jóvenes. Entre los pacientes con cáncer de piel no mortal y un tiempo limitado para vivir, el 70% se sometió a cirugía, según su en JAMA Internal Medicine.

Cuando menos, es más

La cirugía representa un serio riesgo para las personas mayores, que soportan mal la anestesia y cuya piel tarda más en sanar. Entre los adultos mayores que se someten a cirugía abdominal de urgencia, el 20% muere dentro de los 30 días posteriores, según revelan .

Con una disminución de la agudeza mental y un respeto de otra época por la profesión médica, algunos pacientes que envejecen son vulnerables a intervenciones no deseadas. Stanich estuvo de acuerdo con un marcapasos simplemente porque su médico lo sugirió, dijo Giaquinto. Muchas personas de la generación de Stanich “pensaban que los médicos eran como Dios… nunca los cuestionaban, nunca”.

Según la de la Universidad de Michigan, publicada hace pocos días, más de la mitad de los adultos de entre 50 y 80 años dijeron que los médicos a menudo recomiendan pruebas, medicamentos o procedimientos innecesarios. Y la mitad de los pacientes suelen estar de acuerdo, incluso cuando se les dice que el procedimiento puede no ser ciento por ciento necesario.

La doctora Margaret Schwarze, cirujana y profesora asociada de la Facultad de Medicina y Salud Pública de la Universidad de Wisconsin, dijo que los pacientes mayores a menudo no sienten el dolor financiero de la cirugía porque el seguro paga la mayor parte del costo.

Cuando un cirujano ofrece “reparar” la válvula cardíaca en una persona con múltiples enfermedades, por ejemplo, el paciente puede asumir que , dijo Schwarze. “Con pacientes mayores con muchas enfermedades crónicas, realmente no estamos arreglando nada”.

Redberg también lucha para evitar que sus colegas realicen demasiados procedimientos con su madre, Mae, quien tiene 92 años y vive en Nueva York.

Contó que los médicos recientemente trataron a su madre por un melanoma, el tipo más grave de cáncer de piel. Después que le extirparon el cáncer de la pierna, el médico instó a la madre de Redberg a que se sometiera a una cirugía adicional para retirar más tejido y ganglios linfáticos cercanos, que pueden albergar células cancerosas.

“Cada vez que ella iba a una cita, el dermatólogo quería derivarla a un cirujano”, dijo Redberg. Y “Medicare habría estado feliz de pagar por ello”.

Pero dijo que su madre a menudo tiene problemas con la cicatrización de las heridas, y la recuperación probablemente habría demorado tres meses. Cuando Redberg presionó a un cirujano sobre los beneficios, dijo que el procedimiento podría reducir las posibilidades que el cáncer volviera en tres o cinco años.

Redberg dijo que su madre se rio y dijo: “No estoy interesada en hacer algo que me ayudará en tres o cinco años. Dudo que esté aquí”.

Encontrando soluciones

En el mejor de los casos, un paciente puede pasar semanas en el hospital después de la cirugía, para luego pasar el resto de su vida en un hogar. En el peor de los casos, el mismo paciente muere después de estar varias semanas en cuidados intensivos. En el escenario más probable, el paciente sobrevive solo dos o tres meses después de la cirugía.

Schwarze dijo: “Si alguien dice que no puede tolerar el mejor de los casos, entonces quizás no deberíamos estar haciendo esto”.

Maxine Stanich ingresó en el hospital después de ir a la sala de emergencias porque sentía falta de aliento. Ella experimentó un ritmo anormal durante una prueba cardíaca, un evento que no es inusual cuando se inserta un cable en el corazón. Por este episodio, los médicos decidieron implantarle un marcapasos y un desfibrilador al día siguiente.

La doctora Redberg fue consultada cuando la paciente objetó el dispositivo que ahora estaba incrustado en su pecho. Ella estaba “muy alerta”. Tenía muy claro lo que hizo y lo que no quería hacer. Ella me dijo que no quería sorpresas”, dijo Redberg.

Después que Redberg desactivara el desfibrilador, que puede reprogramarse remotamente, Stanich fue dada de alta, con servicio de atención médica en el hogar. Con nada más que sus medicinas, sobrevivió otros dos años y tres meses, muriendo en su casa justo después de cumplir 90 años, en 2010.

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She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Dr. Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital.

“We have a culture that believes in very aggressive care,” said Redberg, who at the University of California-San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.”

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in .

The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people over 65 — involve more than money, said Dr. Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week, according to a .

More than 12 percent of defibrillators were implanted in people older than 80, . Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

led by Dr. Eleni Linos has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her .

When Less Is More

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20 percent die within 30 days, .

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God … They never questioned doctors — ever.”

According to the University of Michigan’s , published Wednesday, more than half of adults ages 50 to 80 said doctors often recommend unnecessary tests, medications or procedures. Yet half of those who’d been told they needed an X-ray or other test — but weren’t sure they needed it — went on to have the procedure anyway.

Dr. Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said that older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”

Even as a doctor, Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Redberg said doctors recently treated her mother for melanoma — the most serious type of skin cancer. After the cancer was removed from her leg, Redberg’s mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

“Every time she went in, the dermatologist wanted to refer her to a surgeon,” Redberg said. And “Medicare would have been happy to pay for it.”

But her mother often has problems with wounds healing, she said, and recovery would likely have taken three months. When Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within three to five years.

Redberg said her mother laughed and said, “I’m not interested in doing something that will help me in three to five years. I doubt I’ll be here.”

Finding Solutions

The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.

The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Dr. Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.

Many hospitals and health systems are developing “decision aids,” easy-to-understand written to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, according to a study in . (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper and the Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.

Schwarze said, “If someone says they can’t tolerate the best-case scenario — which involves them being in a nursing home — then maybe we shouldn’t be doing this.”

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test —not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.

After Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another two years and three months, dying at home just after her 90th birthday in 2010.

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